Mesothelioma Screening Questionnaire

I'm completing this form on behalf of:*

Myself
Another person (living)
Another person (deceased)

Have you ever been diagnosed with mesothelioma or any other type of cancer?*

Yes
No

Was this person diagnosed with mesothelioma or any other type of cancer?*

Yes
No

If yes, which type of cancer?*

Diagnosis date*

Personal Information

Please provide your personal details below.

Patient's Information

Please provide the personal details of the person for whom you are completing this form.

First name*

Middle name*

Last name*

Home address*

Street AddressAddress Line 2CityStateZip Code

Phone number*

Social Security number*

Date of birth*

Date of death*

Marital status*

Spouse's Information

Please provide your spouse's personal details below.

Spouse's Information

Please provide the personal details of the patient's spouse below.

Spouse's first name*

Spouse's last name*

Spouse's date of birth*

Spouse's Social Security number*

Date of marriage*

Is spouse deceased?*

Yes
No

Previous spouse's name (if applicable)

Date of previous marriage (if applicable)

Smoking History

Have you ever smoked?*

Yes
No

Did this person ever smoke?*

Yes
No

Have you quit smoking?*

Yes
No

Did this person quit smoking?*

Yes
No

Year you began smoking*

Year this person began smoking*

Year you quit smoking*

Year this person quit smoking*

Number of packs smoked per day*

Military History

Have you ever served in the military?*

Yes
No

Did this person ever serve in the military?*

Yes
No

If yes, which branch?*

Date enrolled*

Date discharged

Leave blank if still enrolled

Rank*

List ships, shipyards or bases:*

Medical History

Please select "Yes" if you have been diagnosed with the following:

Medical History

Please select "Yes" if this person was diagnosed with the following:

Pleural Plaques/Thickening*

Yes
No

If yes, year of diagnosis?*

Asbestosis*

Yes
No

If yes, year of diagnosis?*

Lung cancer*

Yes
No

If yes, year of diagnosis?*

Mesothelioma*

Yes
No

If yes, year of diagnosis?*

Other cancer*

Yes
No

If yes, year of diagnosis?*

Type of cancer*

Physician Information

Please provide the contact details for the diagnosing physician and any secondary physician that may have provided additional diagnoses.

Diagnosing physician's name*

Physician's address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Physician's phone

Do you have any medical records you can provide regarding the diagnosis?*

Yes
No

Did a secondary physician provide any further diagnoses?*

Yes
No

If yes, what condition(s) did this physician diagnose?*

Secondary physician's name*

Physician's address*

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Physician's phone*

Employment History

Please provide the details of your most recent employer.

Employment History

Please provide the details of this person's most recent employer.

Employer's name*

City*

State*

Position held*

Job site (if different than employer)

Year work began*

Year work ended*

Names of co-workers/supervisors*

Please provide the details for any past employers below.

Employer's name

City

State

Position held

Job site (if different than employer)

Year work began

Year work ended

Names of co-workers/supervisors

Employer's name

City

State

Position held

Job site (if different than employer)

Year work began

Year work ended

Names of co-workers/supervisors

Additional Information

Please answer Yes or No to the following questions.

Have you ever performed home repairs/remodeling?*

Yes
No

Did this person ever peform home repairs/remodeling?*

Yes
No

If yes, what repairs were performed?*

List the type of products used*

Year(s) used*

Have you ever done mechanical repairs on automobiles?*

Yes
No

Did this person ever do mechanical repairs on automobiles?*

Yes
No

Have you been previously screened by this or any other law firm regarding asbestos?*

Yes
No

Was this person previously screened by this or any other law firm regarding asbestos?*

Yes
No

Have you ever applied for Social Security Disability benefits?*

Yes
No

Did this person ever apply for Social Security Disability benefits?*

Yes
No

Date applied*

Date approved or denied*

Have you filed for worker's compensation due to asbestos-related injury?*

Yes
No

Did this person file for worker's compensation due to asbestos-related injury?*

Yes
No

Date claim was filed*

What injury was specified in the claim?*

Bodily injury, disease, etc.

Has this case been settled?*

Yes
No

Have you ever lost time at work due to respiratory problems?*

Yes
No

Did this person ever lose time at work due to respiratory problems?*

Yes
No

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Name:	Email:
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Personal Information

Patient's Information

Spouse's Information

Spouse's Information

Smoking History

Military History

Medical History

Medical History

Physician Information

Employment History

Employment History

Additional Information

Practice Areas