Intake Questionnaire

Client / Contact Information

Injured Party First Name *

Injured Party Last Name *

Cell Phone *

Email Address *

Injured Party Street Address *

Injured Party City *

Injured Party State *

Injured Party Zip Code *

Injured Party Date of Birth *

Injured Party Date of Death

Injured Party SSN

Injured Party Last Four SSN

OBO First

OBO Last

OBO Street Address

OBO City

OBO State

OBO Zip Code

OBO Relationship

Exposure Information

Roundup Exposure type *

If other please describe

Start Date (MM/YY) *

Stop Date (MM/YY) *

Exposure Frequency ( times per year) *

List Roundup products used ( examples Roundup Max Control, Roundup Dual Action, Roundup Ready-To-Use Weed & Grass killer) *

Store Name *

Names of any individuals who witnessed usage and/or exposure to Roundup chemicals and products

Injury Information

Non-Hodgkin's Lymphoma *

Diagnosis Detail / Non-Hodgkins' Lymphoa sub type info *

Date of Diagnosis *

Treating Dr Name *

Treating Dr Specialty *

Treating Facility Name *

Treating Facility Address *

Treating Facility Phone Number *

Diagnosing Dr Name *

Diagnosing Dr Specialty *

Diagnosing Facility Address *

Diagnosing Facility Phone Number *

Diagnosing Facility Name *

Was PNC diagnosed with an autoimmune disease PRIOR to their NHL diagnosis? - If Yes, provide diagnoses and date(s) *

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