This questionnaire is intended to provide basic information necessary to evaluate the merits of any claim for compensation that you may have arising from your E Coli food poisoning. This information will be used for no other purpose and will be kept strictly confidential as required in any attorney/client relationship. However, completion and submission of the questionnaire does not establish such a relationship and no obligations of any kind exist between you and the Law Offices of Rodney A. Klein or the Law Offices of Lawrence S.Paikoff, until further discussions and agreements are reached between the parties and a fee agreement is signed.

Please complete this questionnaire to the best of your ability with as much detail as possible. Required information is indicated in red with an asterisk ("*").

Part I: Personal Information

Please complete this form with the information for the person believed to have suffered damages due to this product.

1. Your current first*, middle, and last* names:
   
   
   
2. All former names (if any) and the years used:
   
   
   
3. Current mailing address:
   
   
   
4. City, State, Zip
   ,
   
   
5. Preferred E-mail address*:
   
   
   
6. Daytime telephone number with area code*:
   e.g. 555-555-1212
   
   
7. Evening telephone number with area code:
   e.g. 555-555-1212
   
   
8. Fax number with area code:
   e.g. 555-555-1212
   
   
9. Date of Birth*:
   e.g. MM/DD/YYYY
   
   
10. Social Security Number:
    e.g. 000-00-0000
    
    

Part II: Medical Information

If you are uncertain of dates, names, addresses, et cetera, please submit the questionnaire, and we will obtain any other necessary information at a later time.

11. Approximate date you believe you ingested the contaminated fresh spinach:
    e.g. MM/DD/YYYY
    
12. Brand of spinach, if purchased by you or family member:
    
13. Where spinach was purchased, if purchased by you or family member:
    
    
14. Address of the Store (if known):
    
15. Name of Restaurant or Deli where you may ingested the cotaminated spinach:
    
    
16. Type of food the contaminated spinach was in:
    
    
17. Have you been treated by a physician or hospital for E Coli food poisoning? If not, please skip to the next question.
    Please Choose... Yes, I did. No, I did not. I don't know.
    
    
18. 1. Approximate date of treatment:
       e.g. MM/DD/YYYY
       
       
    2. Physician or hospital's name where you received this treatment:
       
       
       
    3. Address of the Physician's office or Hospital (if known):
       
       
       
19. Have you been told by your physician that your injury could have been caused by ingesting the contaminated fresh spinach? If not, please skip to the next question.
    Please Choose... Yes, I did. No, I did not. I don't know.
    
    
    

Part III: Symptoms

For each of the following symptoms, please indicate which you have experienced.

Part IV: Comments

Please feel free to write any additional comments in the section below that you feel may be important. This can be supplemental information about something above, or any other issue relating to your Trasylol injection.