QUESTIONNAIRE FOR PROSPECTIVE JURORS
1. Your full name: and your age:
2. List all cities and suburbs where you have lived during the last ten years. Do you own your current home or
rent it, and how long have you lived there?
3. Your highest level of education / degrees awarded:
4. The gender and age of any children:
5. Your current occupation, name of your employer, and number of years employed, including self-employment
(if you are retired, please give this information about your last occupation):
6. What other jobs and employers, including self-employment, have you had during your working life?
7. If you are married and/or in a domestic partnership, describe your spouse’s or partner’s current and immediate
past occupation, employer, and number of years worked there (if spouse or partner is retired, please give this
information about past employment):
8. Please provide the same occupation and employment information about others who live with you (for example,
children, parents, roommates), and any adult children not living with you:
_________________________________________________________________________________________
9. Have you ever served in the military?
10. Have you, your spouse, or partner ever been sued, filed a lawsuit, filed a worker’s compensation claim, or
testified in a deposition or in court? (Include cases you may have been involved in through your employment):
11. Have you ever served on a jury? If so, where, when, and what kind of case (i.e., criminal, civil)?
12. Do you have a regular physician? Do you see your physician regularly? _______________________________
(see back of page for additional questions)
13. Have you ever undergone plastic or cosmetic surgery?
14. Do you have any feelings about people who have chosen to undergo cosmetic surgery, including liposuction?
15. Do you have any feelings about medical malpractice cases in general?
16. Do you have any knowledge of medicine or law? If so, what is your background?
17. Have you, your family, or close circle of friends had a bad experience with health care which would affect
your ability to be fair and impartial to both sides? If so, explain.
18. Have you, your family, or close friends experienced an injury or a complication following surgery? If so, what
type of surgery, and what occurred? Do you believe that this experience would affect your ability to be fair
and impartial to both sides?
19. Do you have any feelings about doctors or the healthcare system that would affect your ability to make a
decision in this case? If so, explain.
20. Have you or any family members treated with DuPage Medical Group?
21. You will learn that this case involves the following issues: surgeons, liposuction, ultrasound assisted
liposuction, Vaser ultrasound cannula, colon perforations, hernias, and sepsis. Do you have any knowledge
about or experience with any of these issues? If yes, what knowledge or experience do you have?
22. Do you have any personal or religious beliefs that would prevent you from sitting in judgment of others?
23. Are there any facts or circumstances you believe that the court or the parties to the case should know that
might affect your ability to serve as a fair and impartial juror in this case?
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