Personal Injury Intake Sheet

PERSONAL INJURY INTAKE SHEET

PERSONAL INFORMATION:

Client’s Name                                                                           

Aliases                                         Date                   

Address                                                                                                            

Phones (H)                                                 

                                                                                                                              

(W)                                                

SSN                                                         Race:                Sex:             Age:            

DOB:                                 

Married? M  S  D  Resides With:                                                              

Phone                                                         

Education: Elem  H.S. Grade       Diploma?                                 

College                                                          

Trade School                                                                                                                                

Spouse’s Name:                                                                    Phones (H)                              

(W)                                 

Address                                          

Employer                                                                                  

                                                                              

                                                                              

Children: Name                                                                   

DOB                                                    Age                        

Name                                                                  

DOB                                                  Age                        

Father’s Name:                                                                     Phones(H)                                  

(W)                              

[ ]L [ ]D Address                            

Employer                                                                                  

                                                                                       

                                                                                       

Mother’s Name:                                                                       

Phones(H)                                   (W)                          

L  D Address             Employer                                                                                 

                                                                                                                           

                                                                                                                           

If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and relationships to decedent of the decedent’s immediate family:

Name:                                                Name:                                                                      

Address:                                             Address:                                                                   

                                                                                                                                           

Telephone:                                         

Telephone:                                                                          

Relation:                                            

Relation:                                                                             

Name:                                               

Name:                                                                                

Address:                                            

Address:                                                                             

____________________________________________________________________________________Telephone:             

Telephone:                                                                          

Relation:                                            

Relation:                                                                             

List the addresses where client has resided during the past 10 years and give the period of time at each residence:

Residence Address                                                                                From/to

                                                                                                                                           

                                                                                                                                           

                                                                                                                                           

EMPLOYMENT INFORMATION:

Name of employer (if unemployed, last employer):                                                                          

Address of employer:

                                                                                                                  

Telephone number:                                            

Personnel Director/Supervisor:                                                                                                

Job title/type of work:

                                                                                                                        

Present rate of pay: $                                               (per week/month/year) Hours worked each

week:                       

Do you regularly work overtime?                If so, indicate approximate amount of time & rate of pay:

                  

Do you receive tips or other type of income?              If so, indicate:

Type of income                               Amount                           Per week/month/year

                                                        $                                per                                           

                                                        $                                per                                           

                                                        $                                per                                           

When did you first begin working for this employer?                                

If unemployed, when did you leave this employer?                                      

Reason for leaving:

                                                                                                                           

What was your reported income in the year before your accident? $                                                

Were you working for your employer at the time the injury occurred?                                              

Have you applied for worker’s compensation benefits as a result of your accident?

                                 

If so, indicate the amounts paid to or received by you to date: $                                              

State your employment history for past ten years:

Name of employer:

                                                                                                                              

Address:

                                                                                                                                          

Period of employment:

From                                                  To                                                          

Position:                                                                                             

Salary:                                

Reason for leaving:

                                                                                                                              

Name of employer:                                                                                                              

Address:

                                                                                                                                          

Period of employment: From                                                   To                                 

Position:                                                                                             

Salary:                                   

Reason for leaving:                                                                                                              

Name of employer:                                                                                                                       

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                  

Position:                                                                                             

Salary:                                

Reason for leaving:

                                                                                                                              

Name of employer:

                                                                                                                              

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                        

Position:                                                                                              Salary:                      

Reason for leaving:                                                                                                                    

Is your spouse employed?       If so, indicate:

Employer’s name:                                                                                Telephone:                

Address of spouse’s

employer:                                                                                                          

Present rate of pay: $              (per week/month/year) Average yearly income of spouse: $

            

How long employed with this employer?                                                       

List spouse’s employment history for past five years:

Name of employer:                                                                                                                       

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                  

Position:                                                                                             

Salary:                                

Reason for leaving:

                                                                                                                              

Name of employer:

                                                                                                                              

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                        

Position:                                                                                              Salary:                      

Reason for leaving:                                                                                                                    

Name of employer:

                                                                                                                              

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                        

Position:                                                                                              Salary:                      

Reason for leaving:                                                                                                                    

Name of employer:

                                                                                                                              

Address:

                                                                                                                                          

Period of employment: From                                                

To                                                        

Position:                                                                                              Salary:                      

Reason for leaving:                                                                                                                    

 

POLICE RECORD:

Have you ever been convicted of a felony?       If so, describe as follows:

1. Date of conviction:                        Place:                                         

Charge:                             

Result:                                                                                                                             

2. Date of conviction:                         Place:                                         Charge:            

Result:                                                                                                                       

Is there now, or has there ever been, a restriction on your driver’s license?

                                                

If so, describe the details of such restriction:

                                                                                                                                                     

 

CLAIMS AND LAWSUITS:

Have you ever been involved in any claim or lawsuit, excluding divorce?                              

If so, list below every claim you have made for money or lawsuits in which you have ever been involved:

Date:                    Place:                                               

Against whom:                                   

Nature of claim:                                                                                                        

Result:                                                                                                                                   

Date:                    Place:                                               

Against whom:                                      

Nature of claim:                                                                                                                  

Result:                                                                                                                                     

INSURANCE INFORMATION:

Name of insurance company:                                                                       

Adjuster’s name:                            Street address:                               

Telephone:                            

City, state, zip:                                                         

Policy number:                                               

Do you have insurance covering damage to your car?                  

Deductible amount: $                       

How much does your insurance cover if you hurt someone else with your car? $                        

Uninsured motorist policy limits:                                             Med Pay Amount $                     

Do you have a second uninsured motorist policy?                                   

If so, fill in the following:

Name of second insurance company:                                                                                    

Address:                                                                                                                 

City, state, zip:                                                                                 

Claim adjuster’s name:                                             

Telephone:               Policy limits: $                                      Policy number:            

Do you have health or accident insurance?       If so, indicate:

Name of health insurance company:                                                                  

Address:                                                                                                       

Telephone:                           Policy #:             

Insurance agent’s name:                                  

Name of accident insurance company:

                                                                                                   

Address:                                                                                                                                

Telephone:                                         Policy #:                            

Insurance  agent’s name:                                          

Have you ever had insurance of any kind declined or cancelled?       If so, give reason:

                                                                                                                                                   

EDUCATION:

Educational background, listing names of schools attended, addresses, years attended and any degrees obtained:

Name & address of school                           Years attended                                Degree

                                                                                                                                

                                                                                                                                

                                                                                                                                

MEDICAL HISTORY BEFORE ACCIDENT

Have you been hospitalized at any time before this accident?       If so, list below all hospitalizations:

Date     Name of Hospital and Doctor                          Duration                          Nature of illness

                                                                                                   ____________________

                                                                                                   ____________________

Have you had any physical examinations before this accident?       If so, list below all physical examinations for five years before this accident:

Date                          Name of Doctor                           Address                                 Purpose

                                                                                                                                        

                                                                                                                                        

                                                                                                                                        

                                                                                                                                        

Have you had any accidents or injuries before this accident?       If so, list below every such accident or injury and whether there was a claim for damages or not:

Date:                       Place:                                                              

Nature of accident/injury:                                                                    

Name of treating physician:                                          claim?      

Date:                       Place:                                                              

Nature of accident/injury:                                                                    

Name of treating physician:                                          claim?      

Date:                       Place:                                                              

Nature of accident/injury:                                                                    

Name of treating physician:                                          claim?      

Have you had any chronic illnesses or diseases before this accident?       If so, list every such illness or disease suffered in the five years before this accident:

                                                                                                                                                   

                                                                                                                                                   

Have you had any other chronic health problems or disabilities?       If so, list them below:

                                                                                                                                                   

                                                                                                                                                   

Did you use any drugs or medication regularly before the accident?       If so, list the type of drug and reason f  or use:

                                                                                                                                                   

                                                                                                                                                   

Have you ever had any broken bones?       If so, give date and circumstances:

Date:              Circumstances:                                                                                        

Date:              Circumstances:                                                                                        

MILITARY BACKGROUND:

Were you in the military service?       Dates: from       to       Type of discharge:               

Branch of service:                      Any service-connected injuries?       If so, describe details:

                                                                                                                                                   

                                                                                                                                                   

                                                                  

Have you received or do you receive payments from VA, social security or other source?      

Claim number:                                                         

FACTS OF THE ACCIDENT:

Date:                          Day:                            Time:                  

Weather conditions:                                                                                  

Describe what happened:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

DIAGRAM:

Indicate on a diagram in the space below what happened. Write in street or highway names or numbers and show direction of travel by arrows. Also, show north by putting an arrow in a circle:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

Show north:      

Were seat belts in use in your vehicle?       If so, who in your vehicle was using a seat belt and who

was not using a seat belt:                                                                                           

Were police called to the scene of the accident?       If so, did the police take photographs of the accident scene?       If so, which police department has possession of such photographs?

                                                            

FACTS CONCERNING THE DEFENDANT:

Name and address of person (defendant) responsible for accident:

Full name of defendant:

                                                                                                                                                   

Street address:

                                                                                                                                                   

City, state, zip:

                                                                                                                                                   

Name of defendant’s employer:

                                                                                                                                          

Name of defendant’s spouse:

                                                                                                                                                   

Name of defendant’s insurance company:

                                                                                                                        

Street address:

                                                                                                                                                   

City, state, zip:

                                                                                                                                                   

Adjuster’s name:                                     Phone                                                                    

Do you know what the defendant’s financial circumstances are without regard to any insurance he might have?       If so, specify:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                  

Give your observations about the defendant as a person:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

Name of 2nd person responsible for accident:

                                                                                                                  

Street address:

                                                                                                                                          

City, state, zip:

                                                                                                                                          

Name of 2nd person’s insurance company:

                                                                                                                  

Address:                                                Claim no:                                                         

Adjuster’s name:                                      Policy no:                      

Policy limits: $                        

Name of 3rd person responsible for accident:

                                                                                                                  

Street address:

                                                                                                                                          

City, state, zip:

                                                                                                                                                

Name of 3rd person’s insurance company:

                                                                                                                                                   

Address:                                                              

Claim no:                                                       

Adjuster’s name:                                        Policy no:                      

Policy limits: $                        

OTHER INJURED PARTIES:

Were other parties, other than the defendant, injured in this accident?       If so, indicate the following:

Name of 2nd injured party: (2nd plaintiff):

                                                                                                                  

Street address:                                                                

Telephone number:                                   

City, state, zip:                                   Birthdate:                                                   

Relationship to you:

                                                                                                                              

Name of 3rd injured party: (3rd plaintiff):

                                                                                          

Street address:                                                                                               

Telephone number:                                   

City, state, zip:                                                         

Birthdate:                                                    

Relationship to you:                                                                                                                       

WITNESSES TO THE ACCIDENT:

List the names, addresses, and telephone numbers of all witnesses to the accident, and any other persons who may be of assistance in testifying about your case, your injuries or changes in your activities since the accident:

Name of 1st witness:                                                                                                                 

Address:                                                                    Telephone:                       Age:      

Employment:                                                                                                                                

Nature of testimony:

                                                                                                                                                   

Name of 2nd witness:

                                                                                                                           

Address:                                                                  Telephone:                       Age:          

Employment:                                                                                                                                

Nature of testimony:

                                                                                                                                                   

Name of 3rd witness:                                                                                                                    

Address:                                                            Telephone:                       Age:                

Employment:                                                                                                                                

Nature of testimony:                                                                                                                     

STATEMENTS MADE:

Have you talked with any police officer, investigator, insurance adjuster or any other person about this incident?       If so, indicate to whom you have spoken, the person’s address and telephone number:

Name                                                               Address                                          Telephone

                                                                                                                                         

                                                                                                                                         

                                                                                                                                         

Have you given a written or recorded statement to any person about this incident? _____ If so, answer the following:

Name of person to whom statement was given:

                                                                                    

Date given:              If written, do you have a copy?       Persons present at time:

                                                                                                                                                   

Did you sign the statement?                                                                   

Did the defendant make any statement to you or in your presence concerning this incident?       If

so, indicate what was said and to whom:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

When and where was the above statement made?

                                                                                    

List the names and addresses of any persons who may have heard it:

Name:                                         

Address:                                                                                

Name:                                            

Address:                                                                                   

Were any statements about the accident made to or taken from anyone else at the scene of the accident?

          If so, describe the name of the person from whom the statement was taken, as follows:

Name:                                                     Telephone number:                                                 

Address:                                                                                                                                      

Nature of statement:                                                                                                                     

Name:                                                        

Telephone number:                                                  

Address:      

Nature of statement:

                                                                                                                                          

DAMAGES FROM ACCIDENT:

The amount of recovery made in this case will be affected by the injuries, damages or expenses incurred as a result of your accident. It is important that you fully list all information regarding your injuries and your expenses as a result of this accident.

State in full detail all injuries you received as a result of this accident:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                      

State your present physical condition such as scars, deformities, headaches, etc.:

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                      

Describe “loss of enjoyment of life” by listing below what normal activities, including sports, hobbies or other activities, you enjoyed before this accident and cannot do now as a result of the accident:

Number of times/week  Number of times/week Activity prior to accident  Since accident

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

                                                                                                                                                   

 

Have you missed time from work as a result of your injuries?      

If so, indicate the following:

From:              To:             From:              To:             From:              To:         

From:              To:            

Did you lose wages for the periods of time missed from work due to this accident?       If so, state the total wages lost to date and the dates:

Wages lost:                                                                                        

Dates:                                    

Wages lost:                                                                                     

Dates:                                    

Have you had any increases or decreases in your pay since the accident?      

If so, explain:

                                                                                                                                                   

                                                                                                                                                   

                                                                              

Did you lose any promotion or merit increase or fringe benefits due to the accident?       If so, describe:

                                                                                                                                                   

                                                                                                                                                   

                                                                                          

If self employed, have you had to hire anyone to take your place      

If so, indicate the costs involved:

                                                                                                                                                   

                                                                                                                                                   

                                                                                          

If you are a student, indicate time lost from school:                                                                         

Indicate period of time you were confined to your home:

                                                                       

Indicate period of time you were confined to bedrest:                                                                   

When is it expected you can return to work?

                                                                                          

List any non-monetary compensation you have lost:

                                                                                                                                                   

                                                                                                                                                   

                                                                                          

Have you been forced to borrow any money as a result of your injuries and inability to work?       If so, describe:

                                                                                                                                                   

                                                                                                                                                   

                                                                                          

Are you able to work part time?       If so, where or what kind of work could you do?                                

                                                                                                                                                   

                                                                                                                                                   

                                                                                          

List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in this accident:

Name of hospital:                                                                                                         

Address:                                                           From:                         To:                       

                                                          Total costs:                                               

Name of hospital:

                                                                                                                                 

Address:                                                                       

From:                        To:                       

                                                                     

Total costs:                                              

Name of hospital:

                                                                                                                                 

Address:                                                                       

From:                        To:                       

                                                                     

Total costs:                                              

List the full name, address and telephone number of each physician who has examined or treated you for your injuries:

Doctor’s name:                                                                    

Telephone:                                               

Address:                                                                                                                             

Specialty:                                                                                                   

Type of treatment:                                                                                                               

Doctor’s name:                                                                    

Telephone:                                               

Address:                                                                                                                             

Specialty:                                                                                                   

Type of treatment:                                                                                                               

Doctor’s name:                                                                    

Telephone:                                               

Address:                                                                                                                             

Specialty:                                                                                                   

Type of treatment:                                                                                                               

Doctor’s name:                                                                    

Telephone:                                               

Address:                                                                                                                             

Specialty:                                                                                                   

Type of treatment:                                                                                                               

Have you used any of the following in connection with treatment?

Wheelchair ……………….. Dates: From            To             

Back or neck brace/collar ….. Dates: From             To             

Crutches …………………. Dates: From            To             

Traction …………………. Dates: From           To             

Physical therapy ………….. Dates: From            To             

Other:                                         Dates: From             To            

List all medications which you have taken for injuries, the name of the doctor prescribing each medication and length of time you took the medication:

Type of medication                    Prescribing doctor’s name                                  Length of time

                                                                                                                                         

                                                                                                                                         

Indicate the amount of all bills/expenses incurred to date as a result of this accident:

$                                              

(attach copies of all such bills, whether paid or unpaid.)

Have you sustained any other injuries since this accident?                               If so, indicate date,

nature of injury and whether you received medical treatment for said injuries:

Date of injury                      Nature of injury                                     Medical treatment

                                                                                                                                         

                                                                                                                                         

PROPERTY DAMAGE:

If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs:

                                                                                                                                                

Telephone number:                              Have you incurred car rental expenses?

$                                  

Where is your vehicle presently located?                                                                               

If any other personal property was damaged, describe said property:

                                                                                                                                                   

Total medical & related expenses to date: $                           Date:                                       

Total of property damage amount to date: $                                       

Date:                               

IMPORTANT

Please collect and attach copies of all medical and related bills incurred to date as a result of this accident, indicating which have been paid and which are still due. Please be sure to forward copies of all future medical bills, drug/medication bills, etc., As they are incurred, even if paid by insurance. See the following two pages for list of items to provide to your attorney and a list of general instructions that will require your attention. In completing this intake sheet, have you thought of any information which I have not asked which may be of some assistance to me in representing you? If so, state it on the back of this form no matter how silly, trivial or embarrassing it may seem.

_______________________________________

Client’s signature

Date: _________________________ 


Attorney Specific Forms

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/


Inside Personal Injury Intake Sheet