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Personal Injury Questionnarie (ATTORNEY-CLIENT PRIVILEGE USE ONLY)
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Step
1
of 4
Your Name:
*
First
Middle
Last
Date and Time of accident:
Date
Time
Location where accident happened (please include address and/or approximate location):
Was a Police Report taken?
YES
NO
Provide the Report/Incident Number and which Agency did the Report (Police, Sheriff, Highway Patrol...etc.):
Where you assessed for any injuries at the scene of the accident?
YES
NO
Who helped you with you injuries (Fire Department, Private Ambulance, ER Services, etc.)?
Were you taken to the hospital?
YES
NO
Please explain how the accident happened in detail:
FOR AUTO, PEDESTRIAN, AND SLIP & FALL ONLY
What was the weather and road conditions like?
As an example: Rain, sunny, wet, dry, slippery, etc.
Next
PERSONAL INFORMATION
Your Birthdate:
Where where you driving on the date of the accident. Please include the route you took along with addesses of your destination if available:
Current Address:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Layout
Your Email:
*
Your Phone #:
List ALL addresses from 5-years prior to the accident/incident:
Name of your current Employer:
If Self-Employed please list here also.
Work phone number:
Address where you work:
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
List ALL places of employment in the last five (5) years BEFORE the accident. Please include Addresses, Dates, Title/Position, Nature of Work for each. If Self-Employed please list here also.
Have you ever been convicted of any Felonies?
YES
NO
What was the offense and when did it occur?
Do you speak English fluently?
YES
NO
Which language and dialect do you normally use to communicate?
Can you read and write in English fluently?
YES
NO
In which language and dialect to you read and write to communicate?
Previous
Next
Prior to the Accident/Incident, did you have any physical, emotional or mental disabilities?
YES
NO
Describe ALL disabilities from PRIOR to Accident/Incident:
Are you suffering any physical, emotional or mental injuries as a result of the Accident/Incident?
YES
NO
Describe where you are experincing Pain and frequency:
Are there recreational or personal physical activities you can no longer do or enjoy as a result of your injuries?
YES
NO
List all activities:
Are you currently receiving any medical treatment from anyone?
YES
NO
List who is providing medical treatment, where, when, and type of medical treatment:
Have you been given any prescription medication(s) for your injuries?
YES
NO
List ALL prescriptions, who prescribed it, when you began and stopped taking the medication(s):
Has any healthcare provider informed you if you will need future treatment(s)?
YES
NO
List name of healthcare provider, name of practice, location, and when & where you where told this?
Previous
Next
EMPLOYMENT
At the time of the Accident/Incident were you employed?
YES
NO
SELF-EMPLOYED
Have you had to take time off work as a result of your injuries?
YES
NO
How many days of work have you missed?
Date your employment started:
What is the last date before the accident/incident that you worked for compensation:
List dates you returned to work at each place of employment following the Accident/Incident:
List dates you did not work and for which you lost income as a result of the Accident/Incident:
What is the total income you have lost to date as a result of the INCIDENT and how was the amount was calculated?
In the past 10 years, have you ever filed any claims or lawsuits for personal injury?
YES
NO
Describe the nature of ALL claims and when it occured:
In the past 10 years have you ever filed a worker’s compensation claim?
YES
NO
Describe the nature of ALL worker's compensation claim(s) and when it occured:
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