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Birth Injury Compensation Claims Questionnaire

MAJOR ISSUES
Please check ALL YOU BELIEVE MAY apply.
 Cerebral Palsy
 Erb's Palsy
 Bone Fracture
 Facial Paralysis
 Brain Damage
 Skull Fracture
 Improper Use of Forceps
 Failure To Perform Timely C-Section
 Proper Techiques Not Used
 Improper Use of Medications
 Wrong Medications Used
 Failure To Provide Proper Care After Delivery
 Failure To Recognize Signs of Problems
 Brachial Plexus Injury
 Stillbirth
 Fetal Distress
 C-Section Mistakes
 Shoulder Dislocation
 Umbilical Cord Problems
 VBAC (Vaginal Birth After Caesarean)
 Hypoxia
 Asphyxia
DAMAGES BELIEVE MAY APPLY
Financial Damages...Check ALL that apply.
 Medical Bills, Rehabilitation, Long Term Care
 Special Education
 Special Household Modifications and Equipment
 Lost Future Earnings
 Pain and Suffering
 Mental and Emotional Distress
 Disfigurement
 Loss of Enjoyment of Life
 
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