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Causes of Injury in the Back, Neck, Lower Body and Feet

Causes of Injury:

Prolonged Standing
Standing on Grates
Repetitive Activation of Foot Pedals
Lifting or Lateral Movement of Legs to Activate Switches

Disorders

Phlebitis
Varicose Veins
Plantar Fascitis
Trocanteric Bursitis
Sore Legs
Swollen Feet

Back / Neck / Lawyer

Free Back, Neck, Lower Body, Feet Disorders Consultation

Title:
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Middle Name:
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Address:	*
City:	*
State, Zip:	* *
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Injured Person Information:

Date of Birth / Age: (ex. mm/dd/yyyy or 54)
Were you injured?	Yes No
If not, who are you inquiring on behalf of?

If you are NOT inquiring on your own behalf,
what is your relationship to the injured person?

Is the person deceased?

Yes No

If deceased, what is the cause of death
as stated on the death certificate:

Date of Death: (ex. mm/dd/yyyy)
Was an autopsy performed?	Yes No
If not deceased, does the injury prevent you or the victim from working?	Yes No

If yes, when did you/victim stop working?
What is the approximate lost wages due to the injury?

Accident / Injury Information:

Date of Injury:	*
City where injury occured:	*
State where injury occured:	*

Please briefly explain the incident that caused the spine/neck/back injury:
Who do you believe was at fault in causing the injury, and what do you believe they did wrong?
Describe the injuries in detail:

Do you believe the injuries are permanent?

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Case Description*
Please explain exactly what happened, trying to state
as thoroughly as possible who you believe was responsible
and why you believe that person was negligent:

Please explain the full extent of the victims injuries:

Comments / Additional Information
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