Practice Tools

Medical Malpractice Interrogatories to Plaintiff

(Amended June 2, 2005, eff. immediately).

1. State your full name, as well as your current residence address, the last four digits of your social security number, date and place of birth, and any other name by which you have ever been known.

 

2. Describe the acts and/or omissions of the defendant(s), i.e., the specific diagnosis, procedure, test, therapy, treatment or other type of healing arts ministration which you claim caused or contributed to the injuries for which you seek damages and, as to each, state:

(a) The date or dates thereof;

(b) The name and address of each witness;

(c) The names and addresses of all other persons having knowledge thereof and as to each such person the basis for his or her knowledge; and

(d) The location of any and all documents, including without limitation, hospital and medical records reflecting such acts and/or omissions.

 

3. State the full name, last known address, telephone number, occupation and/or profession, employer or business affiliation, and relationship to you of each person who has or claims to have knowledge that the defendant(s) deviated from any applicable standard of care in relation to you. As to each such person, state:

(a) The nature of such knowledge;

(b) The manner whereby it was acquired;

(c) The date or dates upon which such knowledge was acquired; and

(d) The identity and location of any and all documents reflecting such deviation.

 

4. Please state the name, address and specialty, if any, of all treating physicians, nurses, medical technicians or other persons practicing the healing arts in any of its branches with whom you or your attorneys have discussed any of the following:

(a) The standard of care owed to you by the defendant(s);

(b) The negligent acts and/or omissions described in your Complaint;

(c) The nature and extent of any injuries suffered by you; and

(d) The relationship between acts and/or omissions on the part of the defendant(s) and such injuries.

 

5. Do you know of any statements made by any person relating to the care and treatment or the damages alleged in the Complaint? If so, give the name and address of each such witness and the date of the statement, and state whether such statement was written or oral and if written the present location of each such statement.

 

6. State the name, author, publisher, title, and date of publication and specific provision of all medical texts, books, journals or other medical literature which you or your attorney intend to use as authority or reference in proving any of the allegations set forth in the Complaint.

 

7. Identify each and every rule, regulation, bylaw, protocol, standard or writing of whatsoever nature by any professional group, association, credentialing body, accrediting authority or governmental agency which you, or your attorney, may use at trial to establish the standard of care owed by the defendant(s), or the breach thereof.

 

8. Please identify and state the location of any of the following documents relating to the issues in this case which either bear the name, handwriting and/or signature of the defendant(s):

(a) Publications and/or professional literature authored by the defendant(s), including publication source and reference;

(b) Correspondence, records, memoranda or other writings prepared by the defendant(s) regarding your diagnosis, care and treatment, other than medical and hospital records in this case; and

(c) Documents prepared by persons other than you or your attorneys which contain the name of the defendant(s).

 

9. Describe the personal injuries sustained by you as the result of the negligent act or omissions described in your Complaint.

 

10. With regard to your injuries, state:

(a) The name and address of each attending physician and/or health care professional;

(b) The name and address of each consulting physician and/or other health care professional;

(c) The name and address of each person and/or laboratory taking any X ray, MRI and/or other radiological tests of you;

(d) The date or inclusive dates on which each of them rendered you service;

(e) The amounts to date of their respective bills for service; and

(f) From which of them you have written reports.

 

11. As the result of your personal injuries, were you a patient or outpatient in any hospital and/or clinic? If so, state the names and addresses of all hospitals and/or clinics, the amounts of their respective bills and the date or inclusive dates of their services.

 

12. As the result of your personal injuries, were you unable to work? If so, state:

(a) The name and address of your employer, if any, at the time of the acts and/or omissions described in the Complaint, your wage and/or salary, and the name of your supervisor and/or foreperson;

(b) The date or inclusive dates on which you were unable to work;

(c) The amount of wage and/or income loss claimed by you; and

(d) The name and address of your present employer and your wage and/or salary.

 

13. State any and all other expenses and/or losses you claim as a result of the acts and/or omissions described in the complaint. As to each expense and/or loss, state the date or dates it was incurred, the name of the person, firm and/or company to whom such amounts are owed, whether the expense and/or loss in question has been paid and, if so, by whom it was so paid, and describe the reason and/or purpose for each expense and/or loss.

 

14. Had you suffered any personal injury or prolonged, serious and/or chronic illness within ten (10) years prior to the date of the acts and/or omissions described in your complaint? If so, state when and how you were injured and/or ill, where you were injured and/or ill, describe the injuries and/or illness suffered, and state the name and address of each physician, or other health care professional, hospital and/or clinic rendering you treatment for each injury and/or chronic illness.

For each physician, or other heath care professional, hospital and/or clinic identified in the preceding paragraph, state the name and address of each insurance company or other entity (health maintenance organization, governmental public assistance program, etc.) which provided to you indemnity, reimbursement or other payment for the medical services received by you and as to each such payor, state the policy number, group number and/or identification number under which you were able to obtain such medical services.

 

15. Have you suffered any personal injury or prolonged, serious and/or chronic illness since the date of the negligent act or omission alleged in your complaint? If so, state when you were injured and/or ill, where and how you were injured and/or ill, describe the injuries and/or illness suffered, and state the name and address of each physician or other health care professional, hospital and/or clinic rendering you treatment for each injury and/or chronic illness.

 

16. Have any other suits been filed for your personal injuries preceding the filing of this lawsuit? If so, state the nature of the injuries claimed, the courts and the captions in which filed, the years filed, and the titles and docket numbers of the suits.

 

17. Have you filed a claim for and/or received workers' compensation benefits? If so, state the name and address of the employer, the date(s) of the accident(s), the identity of the insurance company that paid any such benefits and the case number(s) and jurisdiction(s) where filed.

 

18. Did defendant(s) or anyone associated with defendant(s) give you information or discuss with you the risks involved in the treatment to be given you? If so, state the date(s) and place(s)such information was given, the name(s) of the person(s) providing such information or engaging you in the discussion, and give a description of the information provided or discussed with you.

 

19. Are you claiming any psychiatric, psychological and/or emotional injuries as a result of the acts and/or omissions described in the complaint? If so, state:

(a) The name of any psychiatric, psychological and/or emotional injury claimed, and the name and address of each psychiatrist, physician, psychologist, therapist or other health care professional rendering you treatment for each injury;

(b) Whether you had suffered any psychiatric, psychological and/or emotional injury prior to the date of the acts and/or omissions described in the complaint; and

(c) If (b) is in the affirmative, please state when and the nature of any psychiatric, psychological and/or emotional injury, and the name and address of each psychiatrist, physician, psychologist, therapist or other health care professional rendering you treatment for each injury.

 

20. Pursuant to Illinois Supreme Court Rule 213(f), provide the name and address of each witness who will testify at trial and all other information required for each witness.

 

21. Do you have any photographs, movies and/or videotapes relating to the acts and/or omissions which are described in your complaint and/or the nature and extent of any injuries for which recovery is sought? If so, state the date or dates on which such photographs, movies and/or videotapes were taken, who was displayed therein, who now has custody of them, and the name, address, occupation and employer of the person taking them.

 

22. Have you (or has anyone acting on your behalf) had any conversations with any person at any time with regard to the manner in which the care and treatment described in your complaint was provided, or have you overheard any statement made by any person at any time with regard to the injuries complained of by plaintiff or the manner in which the care and treatment alleged in the complaint was provided? If so, state:

(a) The date or dates of such conversation(s) and/or statement(s);

(b) The place of such conversation(s) and/or statement(s);

(c) All persons present for the conversation(s) and/or statement(s);

(d) The matters and things stated by the person in the conversation(s) and/or statement(s);

(e) Whether the conversation(s) was oral, written and/or recorded; and

(f) Who has possession of the statement(s) if written and/or recorded.

 

23. Have you received any payment and/or other consideration from any source in compensation for the injuries alleged in your complaint? If your answer is in the affirmative, state:

(a) The amount of such payment and/or other consideration received;

(b) The name of the person, firm, insurance company and/or corporation making such payment or providing other consideration and the reason for the payment and/or other consideration; and

(c) Whether there are any documents evidencing such payment and/or other consideration received.

 

24. Identify any statements, information and/or documents known to you and requested by any of the foregoing interrogatories which you claim to be work product or subject to any common law or statutory privilege, and with respect to each interrogatory, specify the legal basis for the claim as required by Illinois Supreme Court Rule 201(n).

 

25. List the names and addresses of all persons (other than yourself and persons heretofore listed) who have knowledge of the facts regarding the care and treatment complained of in the complaint filed herein and/or of the injuries claimed to have resulted therefrom.

 

 

ATTESTATION

STATE OF ILLINOIS )
  ) SS.
COUNTY OF _________________ )

 

__________________________________, being first duly sworn on oath, deposes and states that he/she is a _____________________ in the above-captioned matter, that he/she has read the foregoing document, and the answers made herein are true, correct and complete to the best of his/her knowledge and belief.

 

________________________________________

SIGNATURE

 

SUBSCRIBED and SWORN to before me this

 

_____ day of _____________________, 20___.

 

________________________________________

NOTARY PUBLIC