Hip Replacements Questionnaire

If you are interested in exploring your legal options for a potential claim, please fill out as much as you can of the following form and click on the "Submit" button at the end of the form.

If you would like to discuss this questionnaire with a Client Relations representative, please just fill out your name, phone number and the best time to call.

Thank you.

Name:
Person Responding:
(relationship):
Address: Apt:
City: State: Zip:
Phone# :
Social Security# (optional):
Date of Death:
Marital Status:
Spouse's Name:
(Please provide if you would want you spouse to be included on the claim)
Best time to call:

Date of Surgery:
Hospital and address where surgery took place:
Name of Surgeon:
Manufacturer of Hardware:
How many hip joints were replaced:
Which hip(s)?
LEFT RIGHT BOTH
Has the above hip prosthesis been removed and replaced?
YES NO
If "no", skip the next 7 sub-questions.
Which hip prosthesis was removed and replaced?
LEFT RIGHT BOTH
If the prosthesis has been removed and replaced please provide:
Date of re-operation:
Month:
Date:
Year:
Reason for re-operation:
Date and reasons for any further re-operations:
Did any doctor ever tell you that the hip replacement (s) you received is defective?
YES NO
If yes, who:
If yes, when:
Since the date when the hip replacement was performed have you experienced:
Yes No Groin pain
Yes No Inner thigh pain
Yes No Pain with standing and weight bearing
Yes No Buttock pain
Yes No Significant start-up pain with walking
Yes No Significant start-up pain with rising from a seated position
Yes No Inability to exert resistance in straight leg raising
Yes No Have you contacted any other law firm concerning this litigation?
Yes No Did you sign any papers with any other law firm regarding this litigation?
email address:





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1 (800) 476–6070
e-mail: ClientRelations@weitzlux.com

Please know that you are not considered a client of our firm until your case has been accepted by us, and you have signed a formal “retainer agreement.”