Phone: (971) 205-3266
Website: johnsonlaw.com
Email: info@johnsonlaw.com
Treatment Timeline
Chronological record of all medical appointments and treatments
Patient Name: _________________________________ Date of Accident: ___/___/______
Claim Number: _________________________________ Attorney: Johnson Law, P.C.
Instructions:
- Record all appointments: Include every medical visit related to your accident injuries
- Be thorough: Document the purpose of each visit, findings, and recommendations
- Include all providers: Doctors, specialists, therapists, chiropractors, etc.
- Note follow-up care: Record any prescribed treatments or future appointments
- Track referrals: Document when one provider refers you to another
- Update regularly: Add new appointments as they are scheduled and completed
| Date | Provider Name & Specialty | Type of Visit | Chief Complaint/Reason | Findings/Diagnosis | Treatment Provided | Recommendations/Follow-up |
|---|---|---|---|---|---|---|
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
| ___/___/___ | _____________________ _____________________ | ☐ Initial Visit ☐ Follow-up ☐ Emergency ☐ Therapy ☐ Testing ☐ Other: _______ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ | _________________ _________________ _________________ |
Medical Provider Contact Information
Use this section to record contact information for all your medical providers:
Provider Name: _________________________________
Specialty: _________________________________
Phone: _________________ Fax: _________________
Address: _________________________________
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Treatment Summary
Total Number of Appointments: _______
Number of Different Providers: _______
Date of First Treatment: ___/___/______
Date of Last Treatment: ___/___/______
Types of Treatment Received (Check all that apply):
☐ Emergency Room Care
☐ Primary Care Physician
☐ Orthopedic Specialist
☐ Neurologist
☐ Physical Therapy
☐ Chiropractic Care
☐ Pain Management
☐ Occupational Therapy
☐ Mental Health Counseling
☐ Diagnostic Testing (X-ray, MRI, etc.)
☐ Surgery
☐ Other: ____________________
Ongoing Treatment Needs:
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