Rule 1.1901--Form 19: Health Care Provider Statement in Lieu of Testimony Save Print Instructions Clear Form In the Iowa District Court for Civil case no. County Plaintiff Full name of Plaintiff: first, middle, last vs. Health Care Provider Statement in Lieu of Testimony (and Attorney Certificate) Defendant Full name of Defendant: first, middle, last Patient Name: Type of Incident: Date of Incident: Answer the following questions with information and opinions regarding the named patient. Check this box if you are attaching separate pages for any of your answers to the questions below. Be sure that the question to which your answer relates appears at the top of each additional page. Number of additional pages: 1. What degrees, licenses, and board certifications do you hold, if any, and what year was each attained? Alternatively, you may attach your curriculum vitae. Show Lines Hide Lines 2. What injuries, if any, did Patient sustain in the above-referenced incident? Show Lines Hide Lines 3. Did Patient have any pre-existing, symptomatic conditions that were aggravated by the injuries sustained in the incident? If so, describe the pre-existing conditions and the extent of their aggravation. Show Lines Hide Lines 4. Did Patient have any pre-existing, nondisabling, nonsymptomatic conditions that became symptomatic as a result of the incident? If so, describe. Show Lines Hide Lines January 2015 Rule 1.1901--Form 19 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Rule 1.1901--Form 19: Health Care Provider Statement in Lieu of Testimony, continued 5. What treatment has Patient received from you that was necessitated by the injuries sustained in the incident? Include treatment provided by other care providers to the extent you are aware of such. Include medications prescribed, therapy recommended, surgery recommended and any other treatments needed as a result of this condition. Show Lines Hide Lines 6. Have there been or are there any restrictions or limitations placed on Patient due to injuries sustained in the incident? If so, describe them, including the actual or expected duration of the restrictions or limitations. Show Lines Hide Lines 7. Has Patient made a full recovery from the injuries sustained in the regarding future Patient incident? If not, what are your expectations for symptoms and the duration of such symptoms? Show Lines Hide Lines 8. Is there any additional care or medications that may reasonably be required in the future as a result of the injuries sustained in the incident? If so, describe the expected care, including the expected frequency, duration, and cost. Show Lines Hide Lines 9. Is Patient now susceptible to further health problems in the future as a result of injuries sustained in the incident? If so, explain. Show Lines Hide Lines 10. Is there anything Patient has done or failed to do that has aggravated Show Lines Hide Lines his or her condition or impaired his or her recovery? If so, explain. 11. Have you reviewed or relied upon any medical records other than those generated by you or other providers in your office in forming your opinions to the answers to the questions above? If so, identify or attach the records that you have reviewed and relied upon in forming your answers. Show Lines Hide Lines January 2015 Rule 1.1901--Form 19 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Rule 1.1901--Form 19: Health Care Provider Statement in Lieu of Testimony, continued 12. Have you relied upon any other documents or information about Patient or the incident, other than the records indicated above? If so, state what documents or information you relied upon, and the manner by which you received it. Show Lines Hide Lines Oath and Signature I, Health care provider's name , certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. , 20 Signed on: Month Day Year Health care provider's signature Attorney Certificate on next page January 2015 Rule 1.1901--Form 19 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Rule 1.1901--Form 19: Health Care Provider Statement in Lieu of Testimony, continued Attorney Certificate List any oral, written, or electronic communications between you or anyone in your office and the above-named treating health care provider or anyone in the provider's office regarding . Patient For each such communication, identify the date of the communication and, if the communication was written or electronic, attach copies of such communications: Show Lines Hide Lines Oath and Signature I, Print attorney's name laws of the State of Iowa that the preceding is true and correct. , 20 Month Handwritten signature Day Year Full name: first, middle, last Information supplied by: , certify under penalty of perjury and pursuant to the Law firm, if applicable Mailing address Telephone number Email address Additional email address - if available January 2015 Rule 1.1901--Form 19 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com