Additional Information: Please upload supporting case documents...

Stanley Law Intake Questionnaire

Client Information

*Date *

*Injured’s First Name *

Middle Initial

*Injured's Last Name *

If completing on behalf of injured party, please state your full name

Relationship to injured party/deceased

*Mailing Address *

*City *

County

State *

*Zip *

Home Phone

Work Phone

*Cell Phone *

*Email Address *

Please provide information for two alternate contact people outside the home:

Name (Alternative 1)

Relationship (Alternative 1)

Phone (Alternative 1)

Name (Alternative 2)

Relationship (Alternative 2)

Phone (Alternative 2)

Information Regarding Person Who Used Talcum Powder

*Date of birth *

*Place of Birth (City, State) *

Social Security #

Date of Death (if applicable)

State where person died (if applicable)

Cause of death (if applicable)

*Occupation and Years Worked *

*Marital Status *

Spouse’s Name (if applicable)

*Have you been pregnant? *

*How many children? *

*Are you of Ashkenazi Jewish descent? *

Talcum Powder Information (Please complete on behalf of the injured party)

*Did you use talcum powder in your genital area? *

When did the injured party first start applying talcum powder to the genital region?

*Age at first use: *

*Times Used per Month: *

*Months used per year: (1-12) *

*Overall Years Used: (from what year to what year) *

*When did you first become aware of the connection between talcum powder use and the diagnosis? *

*What State(s) did you live in during the time you used talcum powder? (In Dropdown) *

*What brand(s) of talcum powder have you used? (Check all that apply) *

What brand(s) of talcum powder have you used? If other

*Are you still using talcum powder products in the genital area? *

*Have you been diagnosed with ovarian cancer? *

Have you been diagnosed with ovarian cancer? If yes, when? *

*Have you been diagnosed with Fallopian tube cancer? *

Have You Been Diagnosed With Fallopian Tube Cancer? If Yes, When?

*Have you been diagnosed with uterine cancer? *

Have you been diagnosed with uterine cancer? If yes, when?

*What state did you live in at time of diagnosis? (In Dropdown) *

*Age at time of diagnosis: *

*What stage of cancer were you diagnosed with? *

*What was your HEIGHT at the time of your cancer diagnosis? *

*What was your WEIGHT at the time of your cancer diagnosis? *

*At the time of your initial diagnosis of cancer, which of the following applies? *

Pre-menopausal (still having menstrual periods)

Peri-menopausal (transition years when undergoing menopause)

Post-menopausal (no menstrual periods for at least 1 year)

*Have you undergone genetic testing to determine if you have a predisposition to breast and/or ovarian cancer? BRCA1 *

If the answer is “yes,” please indicate the results below: BRCA1

*Have you undergone genetic testing to determine if you have a predisposition to breast and/or ovarian cancer? BRCA2 *

If the answer is “yes,” please indicate the results below: BRCA2

Please list healthcare providers and/or hospitals you have seen with relation to your cancer and treatment (Use additional pages, if necessary):

*Hospital Name 1 *

*Hospital Address 1 *

*Hospital Phone 1 *

*Date Admitted 1 *

*Date Discharged 1 *

*Did the injured party undergo a hysterectomy and/or oophorectomy at this facility? *

Hospital Name 2

Hospital Address 2

Hospital Phone 2

Date Admitted 2

Date Discharged 2

Injuries Treated/Type of Surgery (2)

*Surgeon Name *

*Surgeon Address *

Surgeon Phone

Date Admitted 3

Date Discharged 3

Injuries Treated/Type of Surgery (3)

*Primary Care Physician Name *

*Physician Address *

*Physician Phone *

*Date First Seen 4 *

Date Last Seen/Still Treating 4

Injuries Treated 4

*OB/GYN Name *

*OB/GYN Address *

*OB/GYN Phone *

*Date First Seen 5

Date Last Seen/Still Treating 5

Injuries Treated 5

Oncologist Name

Oncologist Address

Oncologist Phone

Date First Seen 6

Date Last Seen/Still Treating 6

*Did you receive chemotherapy treatments? *

If you received chemotherapy treatments, state approximate dates

*Were you diagnosed with endometriosis prior to your diagnosis of ovarian cancer? *

If diagnosed with endometriosis prior to diagnosis of ovarian cancer, when were you diagnosed?

If diagnosed with endometriosis prior to diagnosis of ovarian cancer, please list any treatment.

*Have you ever had a tubal ligation? *

If had tubal ligation, indicate when?

*Have you ever used any hormone replacement therapy? *

Name of hormone

Approximate start date (hormone replacement therapy)

Approximate end date (hormone replacement therapy)

*Have you ever used birth control pills? *

Name of birth control

Dates of use (birth control pills)

Prescribing Physician’s Name & Location (birth control pills)

*Have you ever taken any fertility medication? *

Name of fertility drug

Approximate start date (fertility medication)

Approximate end date (fertility medication)

*Have you ever been diagnosed with any other type of cancer prior to your diagnosis of ovarian cancer? *

Name of Cancer 1

Date of Diagnosis 1

Name of Cancer 2

Date of Diagnosis 2

*Do you currently smoke cigarettes? If yes, please answer the questions below. *

For how long have you smoked: (please provide approximate years)

Please indicate how many packs/cigarettes per day have you smoked:

Have you previously smoked? If yes, please answer the questions below.

When did you begin smoking: (please provide approximate date)

How long did you smoke: (please provide approximate years)

Please indicate how many cigarettes/packs per day you smoked until you stopped:

Additional Background Information

*Please indicate if any of your family have been diagnosed with any of the following: (Check all that apply) *

Please indicate if any of your family have been diagnosed with any of the following? If other

Relation to you and please indicate which cancer applies to which family member:

Identify each health insurance carrier that provided coverage for services rendered in relation to your ovarian cancer:

Insurance Company 1

Policy Number 1

Policy Holder 1

Dates of Coverage 1

Insurance Company 2

Policy Number 2

Policy Holder 2

Dates of Coverage 2

Have either you or the injured party ever filed for Bankruptcy?

If yes, please answer the questions below:

Name of Party who Filed Bankruptcy:

Date of Bankruptcy:

Type of Bankruptcy:

Date of discharge:

Is Bankruptcy pending?

Who was the Bankruptcy attorney?

Who was the Bankruptcy attorney? Phone number

Coded Outcome

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