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[VLN-Paraquat] Nadrich Law Intake Questionnaire

Today's Date *

PERSONAL INFORMATION FOR PERSON COMPLETING FORM

First Name *

Maiden Name

Last Name *

Client Address *

Client City *

Client State *

Client Zip Code *

Cell Phone *

Client Home Phone

Email *

Client Social Security Number

Client Birth Date *

Current Age *

Driver’s License Number

Issuing State *

INFORMATION FOR PERSON EXPOSED TO PARAQUAT (IF DIFFERENT THAN ABOVE)

Person Exposed Full Name

Person Exposed Relationship To You

Person Exposed Birth Date

Person Exposed Social Security Number

Person Exposed Cell Phone

Person Exposed Home Phone

Is the person exposed to Paraquat living or deceased?

If deceased:

Date of Death

Cause of Death on Death Certificate

If living:

Do you have power of attorney to sign documents on behalf of this person?

EMERGENCY CONTACT INFORMATION

Emergency Contact Full Name

Emergency Contact Relationship To You

Emergency Contact Full Address

Emergency Contact Telephone

PARAQUAT USE / EXPOSURE

Did you mix Paraquat at Work? *

Mix Paraquat at Work? If yes, What Years?

Did you apply Paraquat at Work? *

Apply Paraquat at Work? If yes, What Years?

Did you mix Paraquat for use on your own property? *

Mix Paraquat for use on your own property? If yes, What years?

Did you apply Paraquat on your own property? *

Apply Paraquat on your own property? If yes, What years?

Did you purchase Paraquat? *

Purchase Paraquat? If yes, What years?

Which Paraquat products did you mix, apply or purchase? (If unknown leave blank)

Did you have license to apply or purchase Paraquat? *

What type of license did you have? (check all that apply)

Where was the license issued? (COUNTY & STATE)

Provide dates when you were licensed? From

Provide dates when you were licensed? To

Please describe how you were exposed to Paraquat. (For example, working in the fields, backpack spray unit, tractor spray, adjacent landowner, etc.) *

PARKINSON’S DISEASE SYMPTOMS & DIAGNOSIS

Have you been diagnosed with Parkinson’s disease? *

When were you diagnosed?

Name of Physician Who Diagnosed You

Full Address of Physician Who Diagnosed You

Phone of Physician Who Diagnosed You

Have you been prescribed medication to treat your Parkinson’s symptoms? *

If yes, check all medications you have been prescribed. (If unknown leave blank)

Medications if other

What are your current Parkinson’s related symptoms? (Check All That Apply) *

Has a doctor told you that your Parkinson’s may be related to Paraquat? *

If Yes, Who told you?

Doctor’s Name

Doctor’s Phone

Doctor’s Address

Do you have any prior history of neurological conditions? *

(If so, please describe in detail and provide date of diagnosis, if known)

Please tell us below any additional information you would like to share regarding your Paraquat exposure and Parkinson’s symptoms/diagnosis

List below every doctor, hospital and clinic that you saw pertaining to your Paraquat related injuries.

1. Provider’s Name & Specialty *

1. Provider’s Full Address and Phone Number

1. Pertaining to your Paraquat dates

2. Provider’s Name & Specialty

2. Provider’s Full Address and Phone Number

2. Pertaining to your Paraquat dates

3. Provider’s Name & Specialty

3. Provider’s Full Address and Phone Number

3. Pertaining to your Paraquat dates

Do you remember when you first experienced any problem or symptom AFTER being exposed to Paraquat?

Symptom 1 Onset *

Symptom 1 Diagnosis

Symptom 1 Date of Diagnosis

Symptom 2 Onset

Symptom 2 Diagnosis

Symptom 2 Date of Diagnosis

How and when did you first become aware that Paraquat may have caused your injuries? Please state how (i.e. reading on the internet, seeing an ad on television, told by a doctor, etc.) Please include approximate date. *

ADDITIONAL QUESTIONS

1) Do you have a family history of Parkinson’s disease? *

If yes, who in your family was diagnosed with Parkinson’s (list relationship to you)

2) Do you recall smelling a strong odor after herbicide had been applied to crops at work, on your land, orapplied to land adjacent to yours? *

If yes, please describe the odor, e.g., pungent, strong, etc

3) If you recall seeing herbicide mixed or applied to crops at work, your land, or on an adjacent landowner’sproperty, do you recall if the herbicide was blue in color? *

4) What crops did you work with (check all that apply) *

Vegetables (list all)

Fruits (list all)

5) If you were exposed to Paraquat at work, please provide a list of all locations/fields where you worked. Try to provide as much information as possible. Attach additional sheets as needed.

1. Location (Street Address/City/State)

1. Employer Name

1. Dates Employed

1. Type of Work You Performed

1. Crop Type

1. How many acres was the worksite?

2. Location (Street Address/City/State)

2. Employer Name

2. Dates Employed

2. Type of Work You Performed

2. Crop Type

2. How many acres was the worksite?

6) If you were exposed to Paraquat at your residence, or via crops/agricultural site adjacent to your land, please provide as much information as you can about your residence/ adjacent land use

Home Address

How big was your lot/land (acreage)?

What crops were grown on your land/property?

Dates You Lived There

Who Owned Adjacent Land? (Name of Company or Individual)

What crops were grown on land adjacent to your property?

How big was the adjacent lot/land (acreage)?

7) Did the adjacent landowner ever use crop dusters to apply herbicide/pesticide?