DEFENDANTS APPROVED MEDICAL MALPRACTICE INTERROGATORIES TO PLAINTIFF (WRONGFUL DEATH) IN THE CIRCUIT COURT OF THE CITY OF ST. LOUIS STATE OF MISSOURI___________________, ) ) Plaintiff, ) ) Cause No. ____________ vs. ) ) Division No. ________________________, ) ) Defendant. ) DEFENDANTS INTERROGATORIES DIRECTED TO PLAINTIFF COMES NOT defendant, and submits the following interrogatories toplaintiff, to be answered in writing and signed under oath, in accordance with theMissouri Rules of Civil Procedure: DEFINITIONS 1. Health care provider shall refer to any medical doctor, osteopath, chiropractor, therapist, psychiatrist, psychologist, social worker, counselor, hospital, medical clinic, or any other provider of diagnostic or therapeutic services. 2. Injury or injured shall refer to any harm or damage to the plaintiffs decedents physical or emotional well being. INTERROGATORIES 1. Please state the following information concerning yourself and the plaintiffs decedent: (a) Full name, social security number, place and date of birth, present address of plaintiff and any other names used; (b) If you or plaintiffs decedent have ever been married, state the full name of each spouse, the date of marriage to each spouse, the date on which each marriage ended, the present address of each spouse and the names, birth dates and present addresses of each child had with each said spouse; (c) Each and every address at which you or plaintiffs decedent have resided in the past ten years including the dates of residence at each address and the names of all persons residing at each address; >>>> 2 DEFENDANTS APPROVED MEDICAL MALPRACTICE INTERROGATORIES TO PLAINTIFF (WRONGFUL DEATH) (d) The highest grade of formal schooling completed, the institution at which it was completed, and any certificates or degrees received including any vocational or specialized education or training in a trade, business or the military; (e) Whether you or plaintiffs decedent have been convicted of or pled guilty to a crime consisting of a misdemeanor or felony and, if so, the offense for which convicted, or to which a guilty plea was entered, the date of conviction or plea, and the name and address of the court where the conviction or plea was entered. (f) Whether plaintiffs decedent was ever a plaintiff in a personal injury suit, proceeding for workers compensation benefits, or a proceeding for social security benefits and, if so, when, where, and in what court the action was commenced; and (g) Whether you or plaintiffs decedent have ever served in the Armed Forces of the United States or of a foreign country. ANSWER: 2. List any job or position of employment, including self-employment, held by plaintiffs decedent, during the period beginning ten years before the first act of negligence alleged in your petition and continuing through the present date, stating as to each, the following: (a) The name and address of the employer; (b) The date of commencement and termination of employment; (c) The place of employment; (d) The nature of employment and the duties performed; (e) The name and address of decedents immediate supervisor; and (f) If a loss of support claim is being made, state the decedents rate of pay or compensation received. ANSWER: 3. State the name and address of each health care provider who has examined or treated plaintiffs decedent during the period beginning ten years before the first act of negligence alleged in your petition and continuing through the present date. For each health care provider identified, state: 2>>>> 3 DEFENDANTS APPROVED MEDICAL MALPRACTICE INTERROGATORIES TO PLAINTIFF (WRONGFUL DEATH) (a) The date of each examination or treatment; (b) The injury, illness, condition, complaint or other reason for which each examination or treatment was conducted; and (c) Whether the injury, illness, condition or complaint for which examination or treatment was performed had been relieved, and if so, the approximate date of relief. ANSWER: 4. State the name and address of each hospital at which plaintiffs decedent had been examined or treated during the period beginning ten years before the first act of negligence alleged in your petition and continuing through the present date. For each hospital identified, state: (a) If admitted, the date of admission and the date of discharge; (b) If not admitted, the date of the visit; and (c) The injury, illness, condition, complaint or other reason for hospitalization or visit. ANSWER: 5. State whether, during the period beginning ten years before the first act of negligence alleged in the petition and continuing through the present day, plaintiffs decedent had suffered any medically significant injury or illness. If so, as to each said injury or illness, state: (a) The date on which the injury took place or illness began; (b) The parts of the decedents body which were injured or affected; and (c) The name and address of each health care provider who treated the plaintiffs decedent for the injury or illness. ANSWER: 6. State whether plaintiffs decedent had been examined or treated by any health care provider following the occurrence(s) mentioned in your petition and for each, state: 3>>>> 4 DEFENDANTS APPROVED MEDICAL MALPRACTICE INTERROGATORIES TO PLAINTIFF (WRONGFUL DEATH) (a) The name and address of each health care provider who examined or treated the decedent; (b) The name and address of each hospital or clinic where the decedent was examined or treated either as an inpatient or outpatient; (c) Describe the treatment or examination rendered; and (d) The total amount of charges by each health care provider, hospital or clinic for services rendered. ANSWER: 7. What expenses, listing them item by item, were incurred in connection with the funeral, burial, cremation or other means of attending to the decedents remains and what is the name and address of each person incurring liability for such expenditures? ANSWER: 8. State whether you have incurred any other expenses not listed in answers to the previous interrogatories which you claim were necessitated by or attributable to the act(s) of negligence alleged in your petition. If your answer is in the affirmative, please state: (a) The product or service for which the expense was incurred; (b) The name and address of the person or entity from whom the product or service was purchased; (c) The date upon which said product or service was