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The Bernstein Approach
 

Nursing Home Neglect or Injury

Step 2 of 3

Please tell us more about the injured person:

Injured person's first name: required field
Injured person's last name: required field
Address:
City:
State:
Zip:
Area code and phone number:
 - -
  Home Work Mobile
Age:
Gender: Male Female
______________________________

Please tell us about the neglect or injury:
Date of neglect or injury:
Name of nursing home:
Location of nursing home - City:
Nursing home location - State:
Brief description of neglect or abuse:
Brief description of injury:
If your loved one suffered bedsores, were the bedsores classified as Grade 4 and/or did they require surgery?
Yes No Unsure
______________________________
Does your loved one suffer from any of these conditions:
Cancer? Yes No Unsure
Hypertension (high blood pressure)? Yes No Unsure
Diabetes? Yes No Unsure
Peripheral vascular disease? Yes No Unsure
Nutritional disorder? Yes No Unsure
Alzheimer's disease? Yes No Unsure
Huntington's disease? Yes No Unsure
______________________________
Did you previously consult another attorney about this injury?
Yes No
Is another attorney currently involved?
Yes No

required field = Required Why?

 
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