PERSONAL INJURY CLIENT QUESTIONNAIRE

CLIENT INFORMATION

Name:
Street Address:
City:
State:
Zip Code:
Home Telephone Number:
Date of Birth:
Social Security Number:
Marital Status:	Single Married Divorced Widowed
Spouse's Name, if applicable:

Children's Names and Dates of Birth, if applicable:

EMPLOYMENT HISTORY

Name of Current Employer:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Occupation (job title):

Job Responsibilities:

Length of time employed by current employer:
Amount of Time Loss Since Injury:
Pay periods are (check one):	Weekly Bimonthly Monthly
Gross income per pay period:
Net income per pay period:
Amount of Wage Loss Since Injury, if known:

FORMER EMPLOYERS WITHIN THE LAST 10 YEARS
(START WITH MOST RECENT AND WORK BACK)

1. Name of Current Employer:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Occupation (job title):
Job Responsibilities:
Dates started and ended employment with previous employer:

2. Name of Current Employer:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Occupation (job title):
Job Responsibilities:
Dates started and ended employment with previous employer:

3. Name of Current Employer:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Occupation (job title):
Job Responsibilities:

If not employed:

Name of last employer:
Occupation (job title):
Dates of employment:
Amount of income received from employment during the last year employed:

Other sources of income besides income from chief employment:

From whom such income is received:
Gross amount:
Net amount:

ACCIDENT

Date of Accident:
Day:
Time:
Location:
Weather Conditions:

Name(s) and Address(es) of other Driver(s) Involved, (if applicable):

Passengers In Any of the Involved Vehicles (if applicable)?
Yes No
If Yes, Please List:

Did the Client Give Any Statements To Anyone?
Yes No
If Yes, Please List:

Were any reports made?
Yes No
If Yes, Please List:

Any Pictures Taken of Scene/Property/Injuries?
Yes No
If Yes, Please List:

Description of Accident (Be very specific):

Are there any statements, notes, medical records, or any other information that is known to be inconsistent or contradicting the facts as described above of the case? If so, Please list:

Names and Addresses of Any Witnesses, if known:

1. Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:

2. Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:

3. Name:
Street Address:
City:
State:
Zip Code:
Telephone Number:

INJURIES

Client's Initial Injuries (Be very specific):

Client's Present Condition:

Client's Treatment (including emergency treatment, hospitals, therapy, and physicians):

1. Name of Provider:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Physician's Specialty:
Dates of Treatment:
Amount of Bill:
Treatment Provided:
Medications Prescribed:

2. Name of Provider:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Physician's Specialty:
Dates of Treatment:
Amount of Bill:
Treatment Provided:
Medications Prescribed:

3. Name of Provider:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Physician's Specialty:
Dates of Treatment:
Amount of Bill:
Treatment Provided:
Medications Prescribed:

4. Name of Provider:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Facsimile Number:
Physician's Specialty:
Dates of Treatment:
Amount of Bill:
Treatment Provided:
Medications Prescribed:

Is there any reason that you feel that there may be a question from the opposition as to the casual connection between the treatment provided and your injuries as a result of this accident? If so, Please List:

PAST MEDICAL AND LITIGATION HISTORY

Has the client ever been in a previous accident?
Yes No
If Yes, Please List:

Has the client suffered from a past serious illness or injury?
Yes No
If Yes, Please List:

Has the client ever been hospitalized?
Yes No
If Yes, Please List:

Has the client visited a doctor for any ailment or injury in the past year?
Yes No
If Yes, Please List:

Has the client ever made a claim against an insurance company for an injury?
Yes No
If Yes, Please List:

Has the client ever been involved in a lawsuit before?
Yes No
If Yes, Please List:

Have you ever been convicted of a felony or a crime involving dishonesty?
Yes No
If Yes, Please List Subject Matter, Parties Involved, Court Number, Court Location, Disposition etc.
:

Medical Bills or Expenses that you have to date.

Note: If you have any medical bills or any other regarding the accident, please mail those bills and other information to our office to be put in your file. If you receive medical bills in future or any other information, please mail it to our office.

Doctor		$
Doctor		$
Doctor		$
Doctor		$
Doctor		$

Hospital		$
Hospital		$
Hospital		$
Hospital		$
Hospital		$

Physical Therapy		$
Physical Therapy		$

X-ray (Taken Where)		$
X-ray (Taken Where)		$

Ambulance		$

Drugs/Prescriptions		$

Medical Equipment		$

Property Damage		$

Other		$

Total Bills to Date:	$

Please provide updated information to Us as to any of the matters contained herein.

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