Standard Form Interrogatories In Medical Malpractice Cases1. State: (b) Any other names you have used or been known by(c) Your date and place of birth(d) Your marital status at the time of the incident(e) Your present marital status(f) Your present home address(g) Your social security no.2. If you claim a permanent injury resulting from the treatment, surgery or examination upon which this action is based, describe such injury fully and in detail.3. Were you ever in the Armed Forces? If so, state: The dates, branch of service, rank at discharge, whether you had any infirmities at discharge, whether you have any claim or are receiving benefits for any infirmities from said service, your Armed Forces service number, and your Veterans "C" number.4. State the name and address of your family physician at the time of the treatment, surgery or examination upon which this action is based. Injuries and Diseases Alleged
5. State in detail the injuries or diseases that you allege that you suffered as a result of treatment, surgery or examination upon which this action is based.Medical Treatment & Reports
6. If you received medical treatment, tests, or examinations (including X-rays) because of injuries or diseases you suffered as a result of the treatment, surgery, or examination referred to in the Complaint, state: (a) The name and address of each hospital at which you were treated or examined; (b) The dates on which each such treatment or examination at a hospital was rendered and the charges by the hospital for each; (c) The name and address of each doctor or practitioner by whom you were treated or examined; (d) The dates on which each such treatment or examination by a doctor or practitioner was rendered and the charges for each; (e) The identity of all reports regarding any medical treatment or examination, setting forth the author and date of such reports; (f) Please consider this as a Request to Produce copies of all reports referred to in the above answer. Prior to Subsequent Injuries or Diseases
7. Either prior to or subsequent to the treatment, surgery or examination referred to in the Complaint, have you ever suffered any injuries, illness or diseases in those portions of the body claimed by you to have been affected by the treatment, surgery or examination referred to in the Complaint? If so, state:
(a) A description of the injuries or diseases you suffered; (b) The date and place of any accident, if such an injury or disease was caused by an accident; (b) The names and addresses of all hospitals, doctors or practitioners who rendered treatment or exami-nations (c) because of any such injuries or diseases; Earnings before the Accident
8. For the period of three years immediately preceding the date of the treatment, surgery or examination referred to in the Complaint, state: (a) The name and address of each of your employers or, if you were self-employed during that period, each of your business addresses and the name of the business while self-employed. (b) The dates of commencement and termination of each of your periods of employment or self-employment. (c) A detailed description of the nature of your occupation and the services performed by you in each employment or self-employment. (d) Your average weekly earnings from each employment or self-employment; the average number of hours worked by you per week in each employment or self-employment; and the amount of income from employment or self-employment reported on your Federal Income Tax Return for each year.Earnings after the Accident
9. If you have engaged in one or more gainful occupations subsequent to the date of the treatment, surgery or examination referred to in the Complaint, state: (a) The name and address of each of your employers or, if you were self-employed, each of your business addresses and the name of the business while self-employed.(b) The dates of commencement and termination of each of your periods and employment or self-employment.(c) A detailed description of the nature of your occupation and the services performed by you in each employment or self-employment.(d) The wage, salary or rate of earnings received by you in each employment or self-employment and the amount of income reported on your Federal Income Tax Return for each year subsequent to the accident.(e) The dates of all absences from your occupation, the reasons therefor and the amount of any earnings lost by you because of such absences.Limitation of Duties and Activities after the Treatment, Surgery or Examination
10. State whether you, subsequent to the date of the treatment, surgery or examination, have been unable to perform adequately any of your customary occupational duties or social or other activities, stating with particularity (a) the duties and/or activities you have been unable to perform, and (b) the periods of time you have been unable to perform, and (c) the names and last known addresses of all persons who have personal knowledge thereof.Witnesses and Those with Knowledge of the Treatment, Surgery or Examination
11. State the name and last known address of each person who (a) was a witness to the treatment, surgery or examination through sight or hearing and/or (b) has knowledge of facts concerning the happening of the treatment, surgery or examination or conditions or circumstances at the time of the treatment, surgery or examination prior to, after, or at the time of the accident, excepting those persons who acquired such knowledge during the course of this litigation.12. With respect to each person identified in the answer to Interrogatory 1(a), state that person's exact location and activity at the time of the treatment, surgery or examination. Statements
13. Have you or anyone acting on your behalf obtained from any person any statement concerning this action or its subject matter? If so, state: (a) The name and last known address of each such person;(b) When, where, by whom and to whom each statement was made, and whether it was reduced to writing or otherwise recorded.(c) The name and address of any person who has custody of any such statements that were reduced to writing or otherwise recorded.(d) Please consider this a Request to Produce those statements referred to in the above answer.Statement Made by Party to Whom Interrogatory is Addressed
14. Have you given any statement concerning this action or its subject matter? If so, state: (a) The name and last known address of each person to whom a statement was given;(b) When and where each statement was given.(c) Please consider this a Request to Produce the statements referred to in the above answer.Photographs, Diagrams or Models
15. Do you know of the existence of any photographs, diagrams or models of the surrounding area or the areas of the treatment, surgery or examination or any other matters or things involved in this treatment, surgery or examination. If the answer is in the affirmative, state:
(a) The date(s) when such photographs, diagrams or models were made;(b) The name and address of the party making them;(c) Where they were made;(d) The objects(s) or subjects(s) each photograph, diagram or model represents.(e) Please consider this a Request to Produce the photographs, diagrams and/or models referred to in the above answer.Trial Preparation Material
16.(A) Have you, or anyone on your behalf, conducted any investigations of the treatment, surgery or examination which is the subject matter of the complaint? (B) If the answer to (A) is in the affirmative, state: (1) The name, address, and employer of all persons who conducted any investigations;(2) The dates of the investigations, and(3) The dates of any reports of any investigations and the identity of the persons who have possession thereof.(4) Please consider this a Request to Produce your investigation reports, except those portions which are protected from discovery by Pennsylvania Rule of Civil Procedure 4003.3.Experts
17.(a) State the name and address of each person whom you expect to call as expert witnesses at trial and state the subject matter on which the expert is expected to testify.(b) For each such expert, state, or have the expert state, the substance of the facts and opinions to which the expert is expected to testify and summarize the grounds for each such opinion. (Expert's reports containing the same information may be attached in lieu of an answer).(c) If the expert is employed and/or self-employed, identify the employer and the nature of employment thereof.(d) Identify all documents submitted to the expert and all products and/or locales inspected by the expert in connection with preparations for his or her testimony.(e) Set forth the qualifications of each expert, listing the schools attended, years of attendance, degrees received, experience in any particular field of specialization or expertise, all publications authored, including the title of the work and the book in which it was printed giving the date of publication. 18. State the specific facts known to you or anyone acting on your behalf upon which you base each claim of negligence or malpractice alleged in this action.19.(a) Were the injuries you allege in this action caused in part by sickness, disease, abnormality or injury other than the injuries you claim resulted from the treatment, surgery or examination upon which this action is based.(b) If so, state specifically the nature of each such sickness, disease, abnormality or injury and how each affected you.(c) Are there any medical, X-rays, hospital or other reports which indicate the nature of each such sickness, disease or abnormality or injury and how each affected you.(d) If so, where and when was each report made and what is the name and present or last known address of the person who made each such report and each such person who has custody or possession of each such report or any copy thereof?(e) Have you been furnished any such information in any way other than by the documents referred to in this Interrogatory? If so, how, when, where and by whom?20. Do you claim that an alleged agent of the defendant caused your injuries because:(a) He/She was not qualified to undertake the type of treatment, surgery or examination he gave?(b) He/She failed to diagnose correctly?(c) He/She did not obtain proper consent or authorization?(d) He/She did not maintain proper standards of hygiene or sterilization?(e) He/She failed to use modern techniques and procedures?(f) He/She did not give the correct treatment?(g) He/She failed to observe proper pre-operative, operative or post-operative procedures, specifying which? (h) He/She was otherwise negligent, specifying the nature of the negligence.(i) Identify the alleged agent.21. Do you claim that an individual defendant caused the injuries because: (a) He was not qualified to undertake the type of treatment, surgery or examination he gave?(b) He/She failed to diagnose correctly?(c) He/She did not obtain proper consent or authorization?(d) He/She did not maintain proper standards of hygiene or sterilization?(e) He/She failed to use modern techniques and procedures?(f) He/She did not give the correct treatment?(g) He/She failed to observe pre-operative, operative, or post-operative procedures, specifying which? (h) He was otherwise negligent, specifying the nature of the negligence. Phil. Cnty. Pa., Standard Form Interrogatories In Medical Malpractice Cases
Former Rule 145A, adopted by the Board of Judges, November 18, 1983, effective 1/3/1983. Amended November 14, 2014, effective 2/17/2015.