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Blindness Injury Lawyer Provides Medical Treatment Worksheet


If you have been injured in an accident, resulting in blindness, vision impairment or any other kind of injury, you need to assure that you get the appropriate treatment and prove all the necessary elements involved in pursuing a personal injury lawsuit.  The below checklist will help you make sure that  you have covered all of the important areas for your case.   Compile all of this information and bring it to your lawyer.  This will particularly helpful when the time for your deposition arrives.  Any questions?  Just give Evan Aidman a call at 610 642 7676.


Injuries as a result of the accident:

Type of pain (sharp, dull, constant or intermittent):


Name and address of ambulance company:

Name and address of emergency room:

Mode of transportation to the emergency room:

Treatment at emergency room:


Orthopedic appliances:

Arrival and departure times:

Mode of transportation home:

Condition for the test of the day/night:

Ability to sleep:

Condition the next morning:

Continued Treatment:

Name, address, phone number and specialty of your family doctor:

Name, address, phone numbers, and specialty of all doctors/therapists seen for your injuries:

Mode of transportation:

Purpose for your visits:

Referral source for each doctor:

Results of first doctor visit:

Results of subsequent visits:

Description of treatments/therapy:



Orthopedic appliances:

Dates of treatment for each doctor/therapist:


Date of last medical treatment:

Continuing Effects:

Pain when discharged:

Medical instructions upon discharge:

Pain since discharge:

Pain today:


Effect of accident on your normal daily activities:

Effect on household duties:

Effect on exercise/sports:

Effect on driving:

Effect on sleeping:

Effect on social activities:

Marital difficulties:

Emotional reaction to your injuries:

Your physical/emotional condition before the accident:

Prior/subsequent accidents:

Prior/subsequent injuries:

Prior/subsequent doctors:

Effect on Work:

Next scheduled day of work after the accident:

Time missed because of the accident:

Reason for missing time:

Effect of accident on ability to work after return to your job:

Work schedule:

Average weekly wage:

Name, phone number, and address of your supervisor:

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