DEFENDANTS APPROVED MED. MAL INTERROGATORIES TO PLAINTIFF 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 NOW defendant and submits the following interrogatories To plaintiff,to be answered in writing and signed under oath in accordance with the MissouriRules 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 physical or emotional well being. INTERROGATORIES 1. Please provide the following information: (a) Your full name, social security number, place and date of birth, present address, and any other names you have used; (b) If you have ever been married, state the full name of each spouse, the date of your marriage to each spouse, the date on which your marriage to each spouse ended, the present address of each spouse and the names, birthdates and present addresses of each child you had with each said spouse; (c) Each and every address at which you have resided in the past ten years including the dates of your residence at each address and the names of all persons residing with you at each address; (d) The highest grade of formal schooling completed by you, the institution at which it was completed, and any certificates or degrees you have received including any vocational or specialized education or training in a trade, business or the military;>>>> 2 DEFENDANTS APPROVED MED. MAL INTERROGATORIES TO PLAINTIFF (e) Whether you have been convicted of or pled guilty to a crime consisting of a misdemeanor or felony and, if so, the offense for which you were convicted, or to which you pled guilty, the date of conviction or plea, and the name and address of the court where you were convicted or pled guilty; (f) Whether you have ever been 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 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 you 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 your immediate supervisor; (f) If you are alleging a loss of income as a result of the acts of negligence alleged in your petition, the rate of pay or compensation received; and (g) The reason for termination. ANSWER: 2>>>> 3 DEFENDANTS APPROVED MED. MAL INTERROGATORIES TO PLAINTIFF 3. Do you claim to have lost time from gainful employment and/or the opportunity for advancement or promotion as a result of the act(s) of negligence alleged in your petition? If so, state: (a) The dates on which and the employment from which said time was lost; (b) Your rate of pay at the time of said loss, the total amount of your loss and your method of computation; (c) The specific condition which you claim caused the loss of time; (d) The name and address of the custodian of wage records at each employer from whom you claim to have suffered a loss of wages; (e) The opportunities which you claim would have been available had the alleged act(s) of negligence not taken place; (f) The name and address of your immediate supervisor or other official at your place of employment who would be responsible for recommending a promotion or advancement. ANSWER: 4. State the name and address of each health care provider who has examined or treated you during the period beginning ten years before the first act of negligence alleged in your petition and continuing through the present date for injuries, complaints or illness relating to the parts of the body insured in the occurrence mentioned in the petition. For each health care provider identified state: (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; (c) Whether the injury, illness, condition or complaint for which examination or treatment was performed has been relieved, and if so, the approximate date of relief. ANSWER: 3>>>> 4 DEFENDANTS APPROVED MED. MAL INTERROGATORIES TO PLAINTIFF 5. State the name and address of each hospital at which you have 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 injuries, complaints or illness relating to the parts of the body injured in the occurrence mentioned in the petition. For each hospital identified, state: (a) If admitted, the date of your admission and the date of your discharge; (b) If not admitted, the date of your visit; and (c) The injury, illness, condition, complaint or other reason for your hospitalization or visit. ANSWER: 6. State whether, during the period beginning ten years before the first act of negligence alleged in your petition and continuing through the present day, you have suffered any injury or illness involving the parts of the body injured in the occurrence mentioned in the petition for which you were evaluated or treated by a physician or other health care provider. 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 your body injured or affected; and (c) The name and address of each health care provider who treated you for the injury or illness. ANSWER: 4>>>> 5 DEFENDANTS APPROVED MED. MAL INTERROGATORIES TO PLAINTIFF 7. Describe each injury you claim to have suffered as a result of the act(s) of negligence alleged in your petition, and for each such injury state: (a) Whether the injury is currently causing you an