Injury Intake Questionnaire

Your Name (required):

Address (required):

City (required):

State (required):

Zip (required):

Home Phone:

Work Phone:

Mobile Phone:

Email Address:

Best method to reach you:

Best times to reach you:

Marital Status:

Number of Children:

Spouse's Name:

Date of Injury:

Where did your injury occur?



How did the injury occur?

Describe how your injury occurred:

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

Describe your injury(ies):

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

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.).

Have you lost income due to your injuries?


If yes, amount of lost income:


Income before injury:


Income after injury:




Employer's address:

Employer's telephone number:

Are you currently working?


Expect to return to work on:

Will not return to work:

Are you in pain? If so, describe:

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.):

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

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

Have you previously consulted an attorney regarding your case?


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

Is your relationship with the attorney ongoing?


Has an attorney declined to represent you in this matter?


If yes, why?

Questions you have about your case: