Contact Helmy Law Firm | Portland Personal Injury Attorney

NOTE: An asterisk (*) indicates REQUIRED information. The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

I. GENERAL INFORMATION - Please tell us how to contact you
1. General
*Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
*Email Address:

II. PERSONAL HISTORY - Please note the following about the person(s) injured or killed:
2. Age - Please state the age of the person who was injured or killed at the time of the incident:
3. Pre-Existing Conditions - Please list and describe any pre-existing medical conditions of the person who was injured or killed:

4. Occupation and employment history - Please tell us about the work history of the person who was injured or killed, as it was before the injury:


III. INJURIES - Please describe the nature of the injury or injuries at issue:
5. Medical Diagnoses and Treatment - Please tell us about any diagnoses made and medical treatments given. Please be sure to include names of diagnosing and treating medical professionals. Also, please discuss any involvement of emergency medical services at the scene of the incident:

6. Prognoses (medical outlook) - Please discuss any impressions that treating doctors have given regarding the medical outlook for the injury or injuries. In addition, please tell us about any treatments that doctors have said will be likely necessary in the future.

7. Effect on Quality of Life - Please describe any lifestyle changes experienced by the injured person and his or her family as a result of the incident. In particular, how (if at all) has the injured person's abilities to enjoy or participate in his or her passions been affected:

8. Economic Impact - Please describe other losses resulting from the injury (lost wages or other income, damaged property, medical costs incurred, other):


*If injured person has died of his or her injuries...*
9. Time and Circumstances - Please note the date, time, and circumstances of the person's death:

10. Cause of Death and Autopsy - Please note the cause of death, as listed on the death certificate. If an autopsy was performed, please state who performed it, when, and where:


IV. PERSONS OR COMPANIES RESPONSIBLE - Please tell us about the person or company who caused the injury, injuries, or death:
11. Person Causing Injury; Person's Employer - Please tell us the name(s) the person(s) who caused the injuries in question. If any such person was working on behalf of an employer at the time of the injury, please provide as much information as you can about the employers in question:

12. Location of Incident / Owner of Premises - Please tell us where the injury occurred. If you know who owned or leased the premises where the injury took place (if applicable), please let us know.

Please NOTE: If a public entity was involved in the injury, you must act quickly to preserve your rights. Under Oregon law, an injured person must notify any public entity of his or her intention to sue within 6 months of the date of injury.

V. CIRCUMSTANCES OF INJURY - Please tell us more about the circumstances of the injury.
13. Time and Place of Injury - When did the injury take place? Where? [Please provide as much detail as possible].

14. Awareness of Injury - If the person who was injured did not become aware of the injury immediately after it occurred, please tell us when and how that person became aware of his or her injuries:

15. Description of Incident - Generally - Please tell us as much as possible about how the incident occurred:


Specific Questions by Type of Incident - For certain kinds of incidents causing injury, it is important to know some additional information.
Please review links below and follow the link for your type of case.
- If the injury arose due to a car accident, truck accident, or motorcycle accident, please click here
- If you believe the injury is related to medical malpractice, please click here
- If you believe the injury is related to a dangerous or defective product, please click here
Please note that some cases may fit more than one of the above descriptions. Accordingly, please provide as much information as you think is appropriate. Please feel free to call us with any questions you may have.

FURTHER QUESTIONS FOR MOTOR VEHICLE CASES
16. Safety Devices - Were you wearing your seatbelt at the time of the crash? If you were driving a motorcycle, were you wearing a helmet? Please discuss:

17. Witnesses - Police Report - Citation Were there any witnesses to the incident? If a police report was filed or citations were issued, please note:

18. Damage to Vehicles - [Body shop, other vehicles at the scene] How would you describe the damage to each of the vehicles at the scene? Please discuss in as much detail as possible, listing (if known) information about any auto body repair shops involved:


FURTHER QUESTIONS FOR MEDICAL MALPRACTICE CASES
19. Opinions of Other Physicians (a) Have you discussed the incident with any doctors who practice medicine in the same field as the physician(s) who caused the injury? If so, please give the names of those physicians.

(b) If you answered "Yes" to 19(a), have any of those doctors given you an opinion as to whether the physicians who caused the injury:
Were negligent? Please discuss.

Violated and/or breached the "standard of care"? Please discuss.

20. Permanent v. Temporary Injury - Have any of the physicians you've spoken to told you that the injuries are the injuries in question likely to be permanent? Please discuss.


FURTHER QUESTIONS FOR DANGEROUS OR DEFECTIVE PRODUCT CASES
21. General Description of Product, Intended Use, and Defect - Please describe for us generally the product you believed caused the injury. If known, please state your understanding of: - the intended purpose of the product - what the product did that was harmful.

22. Manufacturing and Sales Information - Please tell us as much as you can about the manufacturing and sale of the product. Please note - name of manufacturer, - date of manufacture, - All known names of persons and businesses involved in the sale of the product that caused the injury

23. Safety Information / Warnings - Please discuss any and all warnings and safety devices that came with (or were distributed with) the product that caused the injury.

24. Preservation of Evidence - Do you still have the product that caused the injury? If not, what evidence of the product have you preserved, if any? Please discuss.


VI. PREVIOUS ATTORNEY INVOLVEMENT
25. Have you ever... - discussed this matter with another attorney? or - hired another attorney in connection with this matter?
If "yes" in either case, please name those attorneys.


VII. HOW DID YOU FIND US?
26. Please tell us how you learned about this web site.

Serving clients in the State of Oregon, including the cities of Portland, Bend, Tigard, Beaverton, Eugene, Salem, and Ashland. Nation Wide by special arrangements.