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Attorney Injury Intake Questionnaire

Life for an injury victim often times becomes much more difficult after the injury, and the extent of one's injuries is not always clear until days or even months after the incident occurs. Not only does the victim suffer physically (and possibly mentally) as a result of an injury, but now the victim or a representative must deal with doctors, insurance companies, and possibly attorneys. Additionally, injury victims may need to provide documentation to their employer in order to justify (or be reimbursed) for recovery time.

Each of the parties involved will require the victim or a representative to provide them with documentation. If you are an injury victim and planning to file a claim, your attorney will ask a number of detailed questions; so preparing early will make the process much easier (while helping you remember key details).

If you are the person providing the documentation, filling out the form below will prepare you for most of the questions these individuals need answered. You can print this form in either PDF or Microsoft Word format and print it out.

Speak to an Attorney for Free

As you know, the best bet is to contact a local personal injury lawyer for representation. Understanding who is liable for what in a personal injury case can be a complex issue. Failing to obtain such an understanding, however, could prove costly for an injured party. Hiring an attorney who knows the relevant laws in your state will help protect you from unintended outcomes. Fortunately, you can have a qualified personal injury attorney do a free evaluation of your case here.

Also available in PDF | MS Word

Name _____________________________________________

Date of birth ____/____/____

Social security number _____-____-_______

Address ____________________________________________

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Home phone (_____) ______-________

Work phone (_____) ______-________

Mobile phone (_____) ______-________

E-mail address ____________________

Best method to reach you ________________________

Best times to reach you __________________________

Married ____ Single ____ Divorced ____

Number of children ____

If married, spouse's name _________________________

On what date did your injury occur? ____/____/____

Where did your injury occur? City _____________ State _____

How did your injury occur?

__ Aircraft accident

__ Animal bite or attack

__ Assault and battery

__ Defective premises

__ Defective product

__ Police negligence or abuse

__ Medical malpractice

__ Motor vehicle accident

__ Slip or trip and fall

__ Water-related accident

__ Other ________________________

Describe how your injury occurred.

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Who do you believe caused or is responsible for your injury, and why?

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Describe your injury(ies).

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List all doctors and other health care providers who have treated your injuries, including their names, addresses, and telephone numbers.

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Total medical expenses incurred to date for your injuries: $________________

Total medical expenses you expect to incur in the future:  $________________

List the names, addresses, and telephone numbers of all insurance companies that may be involved (including, as applicable, automobile insurer, health insurer, disability insurer, homeowner's insurer, etc.).

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Have you lost income due to your injuries? Yes __ No __

If yes, amount of lost income $_________

Income before injury $__________ per ___________

Income after injury $__________ per ___________

Employer __________________________________________

Position ___________________________________________

Employer's address _____________________________________

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Employer's telephone number (_____) _______-________

Are you currently working? Yes ___ No ___

Expect to return to work on ___/___/___

Will not return to work ___

Are you in pain? If so, describe.

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Describe any other ways in which your life has changed as a result of your injuries. (For example, you are no longer able to engage in athletic activities, your appearance has changed, you cannot care for your children, etc.)

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If married, has your spouse experienced any losses as a result of your injury? If so, describe.

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List the names, addresses, and phone numbers of any possible witnesses in your case.

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Have you previously consulted an attorney regarding your case?

Yes ____ No ____

If yes, provide the attorney's name(s), the firm name(s), the address(es), and the telephone number(s).

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Is your relationship with the attorney ongoing?

Yes ____ No ____

Has an attorney declined to represent you in this matter?

Yes ____ No ____

If yes, why?

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Questions you have about your case:

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Next Steps
Contact a qualified personal injury attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

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