Evaluation Form

Prior Attorney Contact?:	Yes    No
If yes, Attorney Name:
Your Name:
Address:
Address:
City:
State:	Florida
Zip Code:
Telephone:
Cell Phone:
E-Mail Address:
Relationship to Injured Party (If different from above):
Name of Injured Smoker (If different from above):
Year Began Smoking:
Year Ended Smoking:
Spouse at Time of Death:
If No Spouse, Surviving Children:
Physician who diagnosed smoking related illness:
Date of Birth of Injured Person:
Place of Injured Person's Florida Residence in 1996:
Cigarette Brand(s) Smoked:
Date of Diagnosis:
Date of Death (if applicable):
Describe Smoking Related Illness or Disease:   Aortic Aneurysm Bladder Cancer Cerebrovascular Disease Cervical Cancer Chronic Obstructive Pulmonary Disease Coronary Heart Disease Esophageal Cancer Kidney Cancer Laryngeal Cancer Lung Cancer Complications of Pregnancy Oral Cavity/Tongue Cancer Pancreatic Cancer Peripheral Vascular Disease Pharyngeal Cancer Stomach Cancer
Other Chronic Diseases or Illnesses as of 1996: