N.J. R. Appendices Form A(1)
All questions must be answered unless the court otherwise orders or unless a claim of privilege or protective order is made in accordance with R. 4:17-1(b)(3). Information provided in response to these interrogatories shall not be used for any improper purpose. Use of such information shall be in accordance with the Rules of Court, including but not limited to R. 1 :38, and the Rules of Professional Conduct.
(Caption)
1. State your full name, address, date of birth and Social Security number.
2. State the date on which you first came under the medical care of the defendant(s).
3. State the reason(s) you first consulted the defendant(s).
4. State in detail the medical history you gave the defendant(s).
5. Describe the examination performed by the defendant(s) the first time you came under defendant's medical care.
6. Set forth each date on which you presented yourself to defendant(s) for examination and/or treatment and describe in detail the treatment given to you on each date.
7. State the name of each defendant that you contend was negligent, and state what you contend that each such defendant did that should not have been done and what you contend that each defendant did not do that should have been done, and the dates thereof. Set forth all facts on which you base your contentions. If you are relying on any written documents or records, identify those documents and records, and state the material in each document which you contend demonstrates negligence.
8. State the names and addresses of all persons having knowledge of relevant facts relating to this lawsuit and specify those who are eyewitnesses to any act of negligence.
9. State the names and addresses of any and all proposed expert witnesses. Set forth in detail the qualifications of each expert named and attach a copy of each expert's current resume. Also attach true copies of all written reports provided to you by any such proposed expert witnesses.
With respect to all expert witnesses, including treating physicians, who are expected to testify at trial, and with respect to any person who has conducted an examination pursuant to Rule 4:19, state each such witness's name, address and area of expertise and attach a true copy of all written reports provided to you.
State the subject matter on which your experts are expected to testify.
State the substance of the facts and opinions to which your experts are expected to testify and provide a summary of the factual grounds for each opinion.
10. Unless for purposes of impeachment, if you or your expert intend to rely on or use in any way at trial any treatise, identify the treatise by title, author and edition and indicate the pertinent portions to be relied on or used at trial.
11. State whether or not you have been admitted to any hospital or other medical treatment facility in the last ten years and if so, state the name of the hospital or facility, the dates of admission and discharge, the illness, disease or condition that caused such admission and the names and addresses of the doctor(s) who treated you during such admission.
12. State whether you have undergone a physical examination in connection with employment or any application for employment in the last ten years. If so, state the date of any such examination, where it was conducted, who conducted the examination and whether there is a report of such physical examination. If a report was made, attach a true copy. If any such physical examination resulted in action being taken on your behalf or against you, please describe such action.
13. State whether you have ever suffered from any injury or disease other than the condition for which you consulted the defendant(s). If so, specify in detail the nature of each
such injury or disease and the name and present address of each health care provider, if any, whoever provided treatment for the condition.
14. State whether you have ever had a family physician and if so, state physician's name, address and telephone number. Specify and describe any illness or injury for which the family physician has treated you during the past ten years.
15. State whether you have consulted any other health care provider in the past ten years. If so, specify in detail the nature of the condition for which you consulted the health care provider and the name and present address of each health care provider who ever provided treatment for the condition.
16. State whether any admissions or statements were made by any party to this action or their agents, servants or employees and if so, state:
(a) whether oral, written or otherwise recorded;
(b) the date, time and place made;
(c) if oral, the words used, or a summary of same;
(d) if written, attach a copy; and
(e) the names and addresses of all persons present at the time and place the statements or admissions were made.
17. State whether you have ever made a claim or filed a lawsuit against anyone arising out of any personal injury and if so, state for each such claim or lawsuit:
(a) the date and place the injury occurred;
(b) the court or place of filing;
(c) the date of filing;
(d) the names and addresses of all parties and their attorneys;
(e) the nature and extent of all injuries;
(f) the docket or claim number; and
(g) the present status of each such lawsuit or claim and if concluded describe the manner in which the lawsuit or claim was concluded and the payment, if any, you received.
18. Describe the injuries you sustained as a result of the negligence claimed in this lawsuit.
19. If you were treated, attended or examined by any physician(s) or others for the injuries identified in response to Question 18, state:
(a) the names and addresses of all such persons;
(b) whether you were admitted to a hospital or other medical treatment facility and if so provide the name and address of the facility and the dates of admission and discharge;
(c) the dates of every treatment or examination and where they took place; and
(d) state the nature of the medical treatment given by each physician or other person.
(e) if any diagnostic tests were performed, state the type of test performed, name and address of place where performed, date each test was performed and what each test disclosed. Attach a copy of the test results.
20. State whether you are still afflicted with or suffering from the effects of any injury, illness or disability as a result of defendant's negligence. If so, describe in detail.
21. Set forth all claims for economic damages against the defendant(s), including lost wages, and itemize the amounts paid or owed, dates incurred, and the names and addresses of each person to whom paid or owed.
CERTIFICATION
I hereby certify that the foregoing answers to interrogatories are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
I hereby certify that the copies of the reports annexed hereto provided by either treating physicians or proposed expert witnesses are exact copies of the entire report or reports provided by them; that the existence of other reports of said doctors or experts are unknown to me, and if such become later known or available, I shall serve them promptly on the propounding party.
N.J. R. Appendices Form A(1)