What is your relation to the individual that played the video games?
*
Myself
Loved one
Is Injured Party currently going to school?
*
Yes
No
Is the person who played video games a minor (under age of 18)?
*
Yes
No
Highest Level of Education for Gamer?
*
Gender
*
Male
Female
No elements found. Consider changing the search query.
List is empty.
Estimate the date that injured party first started playing video games?
*
On Average how many hours per day gaming?
*
0-1
2-3
3+
Gamertag / PSN ID
*
Select All Gaming Platforms That Have Been Used.
*
Playstation
Xbox
Nintendo Switch
Gaming Computer or Laptop
Steam
Apple iPhone
Android Phone
Oculus VR
Meta Quest
Other Gaming Device
Select all video games that have been played.
*
Apex Legends
Call of Duty
Counter-Strike
Fortnite
GTA 5
League of Legends
Minecraft
Overwatch
Rainbow Six: Seige
Roblox
Teamfight Tactics
Valorant
World of Warcraft
Other Game
What video game that was played first?
*
Please list the game names including the version, dates, and estimated hours spent playing each of the above game. (Optional)
Do you subscribe to any cloud/internet gaming subscription(s) (online gaming subscriptions)
*
Yes
No
Unsure
Which monthly subscription(s) did you purchase?
*
Game Pass Ultimate
Game Pass Core
Xbox Live Gold
Playstation Premium
Playstation Extra
Playstation Essential
EA Play
EA Play Pro
Apple Arcade
Google Play Pass
Amazon Prime Gaming
NVIDIA GeForce NOW
Amazon Luna
Roblox Premium
Ubisoft Classics
Ubisoft Premium
Fortnite Battlepass
Fortnite Crew Subscription
Other Subscription
No Monthly Subscription
Do you have photos, witnesses, or any proof that video games were played/used?
*
Photos
Witnesses
Other Proof
On average how much money per month was spent on video gaming?
*
Do you have receipts for any video games related purchased?
*
Yes
No
Do you use virtual reality headsets, gloves, or other video game accessories?
*
Yes
No
Have you tried to stop or give up gaming?
*
Yes
No
Have you ever watched social media gaming influencers on YouTube. TikTok, or any other websites?
*
Yes
No
Did you pay for additional items in the video games, such as loot, level up options, rewards, badges, or additional game content?
*
Yes
No
Unsure
Did you sell in video game content or loot (level, persons, badges,etc.) for money
*
Yes
No
Did you receive a reward of an energy drink or powder with Battle Pass or other video games?
*
Yes
No
Do not know
Select all internet gaming disorder symptoms that the individual has experienced or has been witnessed since playing video games
*
Poor school or work performance due to playing video games
Withdrawal symptoms when games are taken away such as Sadness, Anxiety or Restlessness, Gamers Rage
Loss of interest in sports, hobbies or spending time with family
Gamer recognizes they have a problem with excessive gaming
Deceives family about gameplay time or steals money to play games
Needs to play more hours on video games to the detriment of education or work
Decline in personal hygiene due to gaming
Failed attempts to stop playing video games
Uses video games to relieve negative moods such as guilt or depression
None of the above
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Have you had any of the following injuries or diagnoses due to video games?
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Diagnosed gaming disorder or addiction
Opposition defiant disorder (ODD)
Suicide attempt
Depression
ADD/ ADHD (Attention deficit hyperactivity disorder)
Gamer's rage
Gamer's thumb
Seizures
Computer vision syndrome
Carpal tunnel syndrome
Orthopedic injury
Sleep Deprivation Psychosis
Anxiety
Other injury
No injury
No elements found. Consider changing the search query.
List is empty.
Have video games affected your life in any of the following ways?*
*
Drop in grades
Dropout of school
Hiding or lying about game playing time
Inability to stop playing games
Poor Hygiene due to excessive video gaming
Received an individualized Education Plan (IEP)
Social isolation
Stealing money for gaming
Withdrawal symptoms
Other Affects
No affects from video games
Have you received any of the following medical treatments due to playing video games?
*
Counseling
Doctor visits
Hospitalization
In person gaming addiction program
Online gaming addiction program
Therapy
Other treatment
No treatment
Did a medical provider diagnosis and/ or treat you for any of the gaming related injuries?
*
Yes
No
Was any medication taken to treat you for any of the gaming related injuries?
*
Yes
No
List any other medical conditions you have been diagnosed with in the past ten years?
*
Have you previously signed documents with an attorney for this claim?
*
Yes
No
Have you filed a lawsuit or been a defendant in a lawsuit?
*
Yes
No
Have you ever been convicted of a misdemeanor or felony?
*
Yes
No
Do you receive SSDI (Social Security Disability Insurance) benefits?
*
Yes
No
Do you receive SSI (Supplemental Security Income) benefits?
*
Yes
No
Emergency Contact Name
*
Emergency Contact Phone #
*
Emergency Contact Relationship to client
*
Legal Full Name of person signing
*
Full Name
*
Email
*
Phone
*
Address
*
Street Address
City
State
Country
Country
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Virgin Islands, U.S.
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List is empty.
Postal code
Date of birth
*
Social Security Number
*
Upload Drivers License
*