Camp Lejeune Questionnaire - PF Law Firm, LLC

Client's Personal Information

Please enter the information of the affected person:

Name

Birthdate

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Best Method and Time to Contact You

Social Security Number

Marital Status

Name of Spouse

Legal Status

Is the client deceased or otherwise do you have power of attorney for them?

Is the Client Deceased or Grantor of Attorney?

Yes
No

Relationship to Client

Name while Living at Camp Lejeune (if different)

Are you the client's power of attorney of executor of their estate?

Power of Attorney or Executor of Estate?

Power of Attorney
Executor of Estate

Is the client deceased?

Is the Client Deceased

Yes
No

Do you have a copy of the client's death certificate to provide to the firm?

Death Certificate Available?

Yes
No

Will the client be able to sign their firm agreement on their own behalf?

Sign Form on Own Behalf?

Yes
No

Please Explain Why

Have you or your relation hired a lawyer connected with Camp Lejeune or your/their injuries?

Previously Hired a Lawyer?

Yes
No
Unknown

Please Explain

About Your Time at Camp Lejeune

Did you ever live or work at Camp Lejeune, or were you stationed there at any point?

Ever Live, Work, Stationed at Camp Lejeune?

Yes
No
Other

Please Explain

Why were you at Camp Lejeune?

Why at Camp Lejeune?

Which Branch while Assigned?

List Unit(s) and Rank(s) while Assigned

Please Explain

Date you began living or working at Camp Lejeune, or best guess:

Date Started Living at Camp Lejeune

Date you stopped living or working at Camp Lejeune, or best guess:

Date Stopped Living at Camp Lejeune

In which location(s) did you live or work while at Camp Lejeune?

Locations Lived or Worked at Camp Lejeune?

Other: Please Explain

Unknown: Please Explain

Please tell us everything you can remember about where you may have lived or worked.

Did you come into contact with the tap water while working or living there?

Come into Contact with Tap Water

Yes
No

Please Explain

Medical Information

Were you diagnosed with any of the following?

Medical Diagnoses

Please provide your diagnosis date(s) and briefly discuss your health issues:

Diagnosis Dates and Health Issues

Please state what documentation you have that discusses your diagnosis:

Diagnosis Documentation Available

Treatment and Healthcare

For the health problems listed in the previous section, please provide:

Name and location of diagnosing or treatment facility:

Doctor’s name:

Most recent appointment date:

Were there additional medical facilities you went to?

Additional Medical Facilities?

Yes
No

Please list the additional facilities. You may leave one or more blank if unapplicable:

Name and location of diagnosing or treatment facility #1:

Name and location of diagnosing or treatment facility #2:

Name and location of diagnosing or treatment facility #3:

Did you have any surgeries as a result of your health problems?

Any Surgeries?

Yes
No

What type of surgery? Or, if unknown, what was the surgery done to correct?

Name and location of the surgical facility:

Have you taken medications for your health problems?

Any Medications?

Yes
No

Please list the medications and provide the name and location of your pharmacy:

Do you have government-affiliated health care coverage?

Have Govt. Health Coverage?

Yes
No

Please select your type(s) of coverage:

Do you have or have you had health insurance?

Have Health Insurance?

Yes
No

Were you ever diagnosed with the same medical condition before you were at Camp Lejeune?

Prior Diagnosis?

Yes
No

Please describe you prior condition:

Please describe anything else we should know, or anything you think is important that you weren’t able to address in previous sections:

Anything Else not Addressed