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Today's Date: Thursday, July 02, 2009
 

Online Evaluation Form

Name:

Email: 

Address:

Phone:



State:

  Zip:
Contact By:

When?  		 


 
ABOUT THE PERSON WITH CEREBRAL PALSY
Name:

Date of Birth / Age:

What is your relationship to the injured? 
Other:
Has a medical diagnosis of CP been made?   Yes  No
If a medical diagnosis of cerebral palsy has been made,
how old was the individual at the time of diagnosis?        
In what state was the child born?

 
MEDICAL INFORMATION
Was the delivery of the child particularly difficult?
Yes  No
Was the birth premature? Yes  No
Did the doctor declare 'fetal distress' during the delivery?
 Yes  No
Do you believe medical errors occurred during labor?
What form of cerebral palsy has been diagnosed?
Please mark all conditions that apply:
Spastic Diplegia
Spastic Quadriplegia
Spastic Hemiplegia
Spastic Double Hemiplegia
Seizures / Epilepsy
Respiratory Difficulty
Vision, Speech, or Hearing Difficulties
Bone Abnormalities (Scoliosis)
Bowel or Bladder Problems
Learning Disabilities
Behavioral Problems
Other / Additional		  
Is full-time care required by either a parent or nurse?
Yes  No
Additional Medical Information:

 
ADDITIONAL INFORMATION

Have you previously sought legal assistance regarding a possible medical malpractice claim? Yes  No

Additional Information / Questions / Comments:
How did you hear about us:

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