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This form might be useful to you if you think you have been exposed to toxic chemicals which have caused health problems. It could help you organize your information and provide a basis on which to evaluate your particular circumstances.

This Case History is intended to be used soley by you and your attorney, should you elect to seek legal counsel. This form is not intended for electronic use or transmittal. To complete this form, you must first print it.

If you have questions about this form or if you wish to contact Rober M. Fellheimer, P.C., please call (215) 885-8851 or e-mail us at info@fellheimerlaw.com.

Contact Information:

First name:

Last name:

Email address:

Company:

Mailing address:

Best way to contact you:

Home Phone
Work Phone
Type of Case
Date of Occurrence
Date of Birth
Marital Status
Single

Married

Divorced

Separated

Dependent Children

(List names, ages)

First Defendant
Name
Address
Phone

Email

Insurer Name

Address

Policy Number

Claim Number

Second Defendant
Name
Address
Phone

Email

Insurer Name

Address

Policy Number

Claim Number

Date and Time of Occurrence.

Exact location

and Municipality

of Occurrence

Describe the Occurrence

Witness Info

Name

Address

Phone

Email

Investigation By:
Charges (List Plaintiff or Defendant):
Municipal Hearings:
Any Admissions or Statements? By Whom?

When?

Those Present:

Written or Oral?

Signed?

Recorded?

Please remember to print and fill in the Medical Data & Personal Details Form by CLICKING HERE.

Describe the Nature of Injuries:

Central Nervous System Injuries (Details)

All Other Injuries or Symptoms Details

Do you symptoms seem to be aggravated by a specific activity?

Have there been any incidents of birth defects since the exposure/occurrence?

Names and addresses/phone numbers for current treating physicians.

Names/Addresses where you received hospital care:
X-RAY and Other Diagnostics Details

Previous Traumatic Injuries

Previous Non-Traumatic Injuries:

Your Family Physician

Date and Reason for the Last Trip to Your Family Physician.

List any current medical program, if applicable.

EMPLOYMENT BACKGROUND

Job Classification:
Length of Time:
Name of Union:
Base HOURLY pay at date of accident:
Base HOURLY pay at date of accident:
Base ANNUAL pay at date of accident:
Bonus and Overtime Pay at date of accident:
Hours per Week
Commissions (if any):

Date Stopped Work:

Date Returned to Work:
Part-Time Employment (Name & Address); If self employed, state here:

Part-Time Employment Earnings (Weekly, Monthly, Annually–please list all three):

Prior Employment (list dates, employer, address):

Disability Benefits:

Please print this form and mail it to our office.

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