ZIP CodeorCity: *

What toxic material were you exposed to?:

Asbestos

Environmental Pollutants

Lead

Mold

Welding Materials

When were you exposed to the toxic material?:

This date:

Over this time period:

Where were you exposed to the toxic material?:

Work

Home

Military Service

Name of unsafe drug:

Reason for taking medication:

Date or dates when drug was used:

Injuries or side effects experienced from using the drug:

Headaches

Nausea

Difficulty sleeping

Anxiety

Difficulty breathing

Impaired vision

Memory loss

Weight gain or loss

Addiction to drug

Pain in body

Depression

Cancer

Lung problems

Heart problems

Brain damage

Seizures

Death on this date:

When did you first begin to experience the injuries or illnesses?:

On this date:

Over this time period:

Has a medical doctor diagnosed these injuries or illnesses?:

Yes, on this date or over this time period:

The status of medical treatment is:

No treatment yet

Still receiving treatment

Stopped treatment but need to restart

Treatment completed

I don't know

Occupation:

The injured party missed this time from work or will likely miss this time from work because of the injury:

No work missed

This number of work days:

This number of work months:

Injured person will return to work on this date:

Injured person is still receiving treatment and is unsure when will return to work

I don't know

This number of work days:

This number of work months:

Injured person will return to work on this date:

Amount of lost work income to date is:

No lost work income

I don't know

$ value:

Marital status:

Single

Married

Legally Separated

Divorced

Widowed

Your Age:

How well do you understand your legal situation or issue? Please select the statement that best applies to your situation:

I understand my legal issue.

I have a couple of questions.

I have a lot of questions.

One Line Summary of your Case: *

Describe your Case in Detail: *

First Name *

Last Name *

City *

State or Province *

Zip / Postcode *

Phone *

Email *

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