Personal Injury Intake Questionnaire

PERSONAL INJURY CLIENT INTAKE QUESTIONNAIRE

SECTION 1: CLIENT INFORMATION

Primary Contact Information

Full Legal Name: [________________________________]

Also Known As / Maiden Name: [________________________________]

Date of Birth: [__/__/____] Age: [___]

Social Security Number: [___-__-____]

Current Address:
Street: [________________________________]
City: [________________] State: [____] Zip: [________]

Mailing Address (if different):
Street: [________________________________]
City: [________________] State: [____] Zip: [________]

Contact Numbers:

• Home: [(___)___-____]
• Cell: [(___)___-____]
• Work: [(___)___-____]

Email Address: [________________________________]

Preferred Contact Method: ☐ Phone ☐ Email ☐ Text ☐ Mail

Best Time to Contact: [________________________________]

Language Preference: [________________________________]

Interpreter Needed: ☐ Yes ☐ No If Yes, Language: [________________]

SECTION 2: EMERGENCY CONTACT

Name: [________________________________]

Relationship: [________________________________]

Phone: [(___)___-____]

Address: [________________________________]

SECTION 3: INCIDENT INFORMATION

Date, Time, and Location

Date of Incident: [__/__/____]

Time of Incident: [____:____ AM/PM]

Location of Incident:
Street/Intersection: [________________________________]
City: [________________] State: [____] Zip: [________]
County: [________________________________]

Type of Incident

☐ Motor Vehicle Accident
☐ Motorcycle Accident
☐ Pedestrian Accident
☐ Bicycle Accident
☐ Slip and Fall
☐ Trip and Fall
☐ Premises Liability
☐ Product Liability
☐ Dog Bite/Animal Attack
☐ Medical Malpractice
☐ Nursing Home Negligence
☐ Construction Accident
☐ Workplace Injury
☐ Assault/Battery
☐ Wrongful Death
☐ Other: [________________________________]

Incident Description

Describe what happened in your own words:
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

Weather Conditions: ☐ Clear ☐ Rain ☐ Snow ☐ Ice ☐ Fog ☐ Other: [________]

Road/Surface Conditions: ☐ Dry ☐ Wet ☐ Icy ☐ Debris ☐ Construction ☐ Other: [________]

Lighting Conditions: ☐ Daylight ☐ Dawn/Dusk ☐ Night - Lit ☐ Night - Unlit

SECTION 4: MOTOR VEHICLE ACCIDENT DETAILS (if applicable)

Your Vehicle

Year/Make/Model: [________________________________]

License Plate: [________________] State: [____]

VIN: [________________________________]

Registered Owner: [________________________________]

Where is the vehicle now: [________________________________]

Vehicle Damage: ☐ Minor ☐ Moderate ☐ Severe ☐ Totaled

Your Position in Vehicle

☐ Driver ☐ Front Passenger ☐ Rear Passenger - Left ☐ Rear Passenger - Right ☐ Rear Passenger - Center

Were you wearing a seatbelt: ☐ Yes ☐ No

Did airbags deploy: ☐ Yes ☐ No ☐ Unknown

Other Vehicle(s) Involved

Vehicle 1:
Driver Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Insurance Company: [________________________________]
Policy Number: [________________________________]
Year/Make/Model: [________________________________]
License Plate: [________________] State: [____]

Vehicle 2 (if applicable):
Driver Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Insurance Company: [________________________________]
Policy Number: [________________________________]
Year/Make/Model: [________________________________]
License Plate: [________________] State: [____]

SECTION 5: WITNESSES

Witness 1:
Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Email: [________________________________]
Relationship to Client: [________________________________]

Witness 2:
Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Email: [________________________________]
Relationship to Client: [________________________________]

Witness 3:
Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Email: [________________________________]
Relationship to Client: [________________________________]

SECTION 6: POLICE/INCIDENT REPORT

Was police called: ☐ Yes ☐ No

Responding Agency: [________________________________]

Report Number: [________________________________]

Officer Name/Badge: [________________________________]

Were citations issued: ☐ Yes ☐ No

If yes, to whom and for what: [________________________________]

Were you taken to a hospital by ambulance: ☐ Yes ☐ No

Ambulance Company: [________________________________]

SECTION 7: INJURIES

Injuries Sustained

☐ Head/Brain Injury
☐ Neck/Cervical Spine
☐ Back/Thoracic Spine
☐ Lower Back/Lumbar Spine
☐ Shoulder (Left/Right): [____]
☐ Arm (Left/Right): [____]
☐ Elbow (Left/Right): [____]
☐ Wrist (Left/Right): [____]
☐ Hand/Fingers (Left/Right): [____]
☐ Hip (Left/Right): [____]
☐ Leg (Left/Right): [____]
☐ Knee (Left/Right): [____]
☐ Ankle (Left/Right): [____]
☐ Foot/Toes (Left/Right): [____]
☐ Ribs/Chest
☐ Internal Injuries
☐ Lacerations/Scarring
☐ Psychological/Emotional
☐ Other: [________________________________]

Describe your injuries in detail:
[________________________________]
[________________________________]
[________________________________]

Current Symptoms

☐ Pain
☐ Numbness/Tingling
☐ Weakness
☐ Limited Range of Motion
☐ Headaches
☐ Dizziness
☐ Memory Problems
☐ Sleep Disturbance
☐ Anxiety/Depression
☐ Other: [________________________________]

Pain Level (1-10): [___]

SECTION 8: MEDICAL TREATMENT

Emergency Treatment

Emergency Room Visited: ☐ Yes ☐ No

Hospital Name: [________________________________]

Date: [__/__/____]

Admitted to Hospital: ☐ Yes ☐ No

Length of Stay: [________________________________]

Ongoing Treatment

Primary Care Physician:
Name: [________________________________]
Address: [________________________________]
Phone: [(___)___-____]
Date of First Visit Post-Accident: [__/__/____]

Specialists Seen (list all):

Physical Therapy:
Facility: [________________________________]
Phone: [(___)___-____]
Dates: From [__/__/____] to [__/__/____]
Frequency: [________________________________]

Chiropractic Treatment:
Provider: [________________________________]
Phone: [(___)___-____]
Dates: From [__/__/____] to [__/__/____]
Frequency: [________________________________]

Diagnostic Testing

☐ X-rays Location: [________________________________]
☐ CT Scan Location: [________________________________]
☐ MRI Location: [________________________________]
☐ EMG/Nerve Conduction Location: [________________________________]
☐ Other: [________________________________]

Surgeries

Have you had surgery as a result of this incident: ☐ Yes ☐ No

If yes, describe:
| Procedure | Date | Surgeon | Facility |
|-----------|------|---------|----------|
| [____________] | [____________] | [____________] | [____________] |

Are future surgeries planned: ☐ Yes ☐ No

If yes, describe: [________________________________]

SECTION 9: PRE-EXISTING CONDITIONS

Did you have any injuries or conditions to the same body parts before this incident: ☐ Yes ☐ No

If yes, describe:
| Body Part | Condition | When | Treatment Received |
|-----------|-----------|------|-------------------|
| [____________] | [____________] | [____________] | [____________] |
| [____________] | [____________] | [____________] | [____________] |

Prior motor vehicle accidents: ☐ Yes ☐ No

If yes:
| Date | Description | Injuries | Attorney Used |
|------|-------------|----------|---------------|
| [____________] | [____________] | [____________] | [____________] |

Prior workers' compensation claims: ☐ Yes ☐ No

If yes, describe: [________________________________]

Prior personal injury claims: ☐ Yes ☐ No

If yes, describe: [________________________________]

SECTION 10: MEDICARE/MEDICAID/LIEN IDENTIFICATION

Government Health Benefits

Are you a Medicare beneficiary: ☐ Yes ☐ No
Medicare Number (HICN/MBI): [________________________________]
Part A Effective Date: [__/__/____]
Part B Effective Date: [__/__/____]
Medicare Advantage Plan: ☐ Yes ☐ No
Plan Name: [________________________________]

Are you enrolled in Medicaid: ☐ Yes ☐ No
Medicaid Number: [________________________________]
State: [____]

Do you receive Social Security Disability (SSDI): ☐ Yes ☐ No

Do you receive Supplemental Security Income (SSI): ☐ Yes ☐ No

Are you eligible for Medicare within 30 months: ☐ Yes ☐ No

Other Government Programs

Veterans Administration (VA) Benefits: ☐ Yes ☐ No

TRICARE/Military Insurance: ☐ Yes ☐ No

Indian Health Services: ☐ Yes ☐ No

SECTION 11: HEALTH INSURANCE INFORMATION

Primary Health Insurance

Insurance Company: [________________________________]

Policy Holder Name: [________________________________]

Relationship to Client: [________________________________]

Policy Number: [________________________________]

Group Number: [________________________________]

Claims Address: [________________________________]

Phone: [(___)___-____]

Is this an ERISA plan (employer-sponsored): ☐ Yes ☐ No ☐ Unknown

Secondary Health Insurance

Insurance Company: [________________________________]

Policy Number: [________________________________]

Group Number: [________________________________]

SECTION 12: AUTOMOBILE INSURANCE INFORMATION

Your Auto Insurance

Insurance Company: [________________________________]

Policy Number: [________________________________]

Agent Name: [________________________________]

Agent Phone: [(___)___-____]

Claims Phone: [(___)___-____]

Coverage Limits

Bodily Injury Liability: $[________]/$[________]

Property Damage: $[________]

Medical Payments (MedPay): $[________]

Personal Injury Protection (PIP): $[________]

Uninsured Motorist (UM): $[________]/$[________]

Underinsured Motorist (UIM): $[________]/$[________]

Collision Deductible: $[________]

Comprehensive Deductible: $[________]

Other Household Auto Policies

Do other household members have auto policies: ☐ Yes ☐ No

If yes, list (may provide stacking UM/UIM coverage):
| Policyholder | Insurance Company | Policy Number | UM/UIM Limits |
|--------------|-------------------|---------------|---------------|
| [____________] | [____________] | [____________] | [____________] |

SECTION 13: LOST WAGES AND EMPLOYMENT

Employment at Time of Incident

Employment Status: ☐ Employed ☐ Self-Employed ☐ Unemployed ☐ Retired ☐ Disabled ☐ Student

Employer Name: [________________________________]

Employer Address: [________________________________]

Employer Phone: [(___)___-____]

Your Job Title: [________________________________]

Date Hired: [__/__/____]

Supervisor Name: [________________________________]

Hourly Rate / Salary: $[________] per [________]

Average Hours per Week: [____]

Average Weekly Gross Income: $[________]

Time Missed from Work

First Day Missed: [__/__/____]

Date Returned to Work: [__/__/____] ☐ Not Yet Returned

Total Days Missed to Date: [____]

Are you working reduced hours: ☐ Yes ☐ No

If yes, explain: [________________________________]

Are you working light duty: ☐ Yes ☐ No

If yes, explain: [________________________________]

Lost Earning Capacity

Has your ability to work been affected long-term: ☐ Yes ☐ No

If yes, explain: [________________________________]

SECTION 14: LOSS OF CONSORTIUM (if applicable)

Are you married: ☐ Yes ☐ No

Spouse Name: [________________________________]

Date of Marriage: [__/__/____]

Has your injury affected your marital relationship: ☐ Yes ☐ No

If yes, describe: [________________________________]

SECTION 15: OUT-OF-POCKET EXPENSES

List all expenses incurred as a result of this incident:

SECTION 16: PROPERTY DAMAGE

Was your property damaged: ☐ Yes ☐ No

Description of Damaged Property:
[________________________________]

Estimated Value: $[________]

Has a claim been filed: ☐ Yes ☐ No

Claim Number: [________________________________]

Has property been repaired/replaced: ☐ Yes ☐ No

Repair Cost: $[________]

SECTION 17: PHOTOGRAPHS AND EVIDENCE

Do you have photographs of:

☐ The accident scene
☐ Vehicle damage
☐ Your injuries
☐ Property damage
☐ Road conditions
☐ Traffic signals/signs
☐ Other: [________________________________]

Is there surveillance video available: ☐ Yes ☐ No ☐ Unknown

Location: [________________________________]

Were there any dashcams involved: ☐ Yes ☐ No

SECTION 18: PRIOR ATTORNEYS

Have you consulted with other attorneys about this case: ☐ Yes ☐ No

If yes:
| Attorney Name | Firm | Date | Outcome |
|--------------|------|------|---------|
| [____________] | [____________] | [____________] | [____________] |

Have you signed a retainer agreement with another attorney: ☐ Yes ☐ No

If yes, provide details: [________________________________]

SECTION 19: CRIMINAL/CIVIL HISTORY

Have you ever been convicted of a felony: ☐ Yes ☐ No

If yes, describe: [________________________________]

Have you ever filed for bankruptcy: ☐ Yes ☐ No

If yes: Date: [__/__/____] Chapter: [____] Status: [________________________________]

Are there any outstanding judgments against you: ☐ Yes ☐ No

Do you have any pending lawsuits: ☐ Yes ☐ No

SECTION 20: ADDITIONAL INFORMATION

Is there anything else you would like us to know about your case:
[________________________________]
[________________________________]
[________________________________]

How did you hear about our firm:
☐ Referral from: [________________________________]
☐ Internet Search
☐ Social Media
☐ Television
☐ Radio
☐ Billboard
☐ Prior Client
☐ Other: [________________________________]

INTAKE CHECKLIST

☐ Photo ID copied
☐ Insurance cards copied
☐ Police report obtained
☐ Medical records authorization signed
☐ Employment records authorization signed
☐ Insurance authorization signed
☐ Retainer agreement signed
☐ Client photos taken (injuries)
☐ Preservation letter sent
☐ Medicare/Medicaid status verified
☐ Lien investigation initiated
☐ Conflict check completed
☐ Case opened in system

CLIENT CERTIFICATION

I certify that the information provided above is true and accurate to the best of my knowledge. I understand that providing false information may adversely affect my case and my relationship with my attorney.

Client Signature: _________________________________ Date: [__/__/____]

Printed Name: _________________________________

Intake Completed By: _________________________________ Date: [__/__/____]

Attorney Review: _________________________________ Date: [__/__/____]