Personal Injury Intake Form

Published on May 2016 | Categories: Types, Research, Law | Downloads: 64 | Comments: 0 | Views: 431
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Here is the sample intake form which needs to be filled out by the client or his dependent. It covers all the information that need to be entered into Personal Injury Case Management Software.

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Content

PERSONAL INJURY INTAKE FORM
—CONFIDENTIAL—
DEAR CLIENT, YOU HAVE MADE A WISE DECISION TO ASSIGN YOUR CASE TO OUR LAW FIRM. ALL
THE INFORMATION YOU PROVIDE HERE IS VITAL TO ASSESS YOUR CASE AND HELPFUL TO CLAIM FOR
MAXIMUM COMPENSATION. PLEASE PRINT THIS WORKSHEET AND PROVIDE THE INFORMATION
BELOW. IF YOU DO NOT KNOW THE ANSWER TO A QUESTION LEAVE IT BLANK.

DATE:

ATTORNEY NAME:

CASE FILE NO:

CLIENT INFORMATION
1.

PERSONAL INFORMATION

NAME: ___________________________________________________________________________
ADDRESS:__________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________
HOME PHONE: _____________________

WORK PHONE: ____________________ __________

FAX NUMBER: _____________________

E-MAIL: ___________________________________

DATE OF BIRTH:____________________

SOCIAL SEC. NO.: ___________________________

NATIONALITY: _____________________

CELL PHONE: _______________________________

BEST TIME TO CONTACT: _____________________________________________________________
ARE YOU AN EXISTING CLIENT?

YES [ ]

HOW DID YOU HEAR ABOUT US: GOOGLE [ ]

NO [ ]
CLIENT REFERRAL [ ]

ATTORNEY REFERRAL [ ]

NAME OF THE CLIENT OR ATTORNEY WHO REFEERRED YOU:_______________________________
PREFERRED LANGUAGE: ENGLISH [ ]
MARITAL STATUS:

SPANISH [ ]

SINGLE [ ]

MARRIED [ ]

DIVORCED [ ]

IF MARRIED PROVIDE AN INFORMTION AS BELOW
SPOUSE NAME: ___________________________________________________________________
ADDRESS: ________________________________________________________________________
_________________________________________________________________________________

1

PERSONAL INJURY INTAKE FORM
HOME PHONE: _____________________

WORK PHONE: ____________________ _________

FAX NUMBER: _____________________

E-MAIL: ___________________________________

DATE OF BIRTH:____________________

SOCIAL SEC. NO.: ___________________________

NATIONALITY: _____________________

CELL PHONE: _______________________________

OCCUPATION _____________________________________________________________________
SPOUSEC EMPLOYER AND ADDRESS_____________________________________________________
_________________________________________________________________________________

CHILDREN NAME, AGE AND EDUCATION:
1. __________________________________________
2. __________________________________________

OTHER DEPENDENTS NAME, AGE, RELATIONSHIP, AND LOCATION:
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________

2. INFORMATION ON THE CLIENT EDUCATION
EDUCATION: ____________________________________________________________________
YEAR OF COMPLETION: ____________________________________________________________

3. INFORMATION ON THE CLIENT EMPLOYMENT
EMPLOYEE [ ]

SELF EMPLOED [ ]

OWNS A BUSINESS [ ]

UNEMPLOYED [ ]

NAME OF EMPLOYER:________________________________________________________________
POSITION:________________________________________________________________________
HOW LONG YOU WERE EMPLOYED WITH THIS EMPLOYER?______________________________ ___
MONTLY INCOME:___________________________________________________________________
2

PERSONAL INJURY INTAKE FORM

EMPLOYMENT ADDRESS:_____________________________________________________________
_________________________________________________________________________________
TELEPHONE:__________________________________ FAX NO.:____________________________
SUPERVISOR NAME AND TELEPHONE NO.:_______________________________________________
DATES OF WORK MISSED:_____________________________________________________________
TOTAL LOST WAGES: _______________________________________________________________

4. INFORMATION ON BUSINESS:
DO YOU OWN A BUSINESS? YES [ ] NO [ ]
BUSINESS NAME :___________________________________________________________________
BUSINESS LOCATION:________________________________________________________________
_________________________________________________________________________________
MONTHLY BUSINESS INCOME: ________________________________________________________

5. INFORMATION ON ANY OTHER ATTORNEYS YOU HAVE CONTACTED REGARDING THIS MATTER:
ATTORNEY NAME AND LOCATION:________________________________________________
CONTACT DATE: _________________________________________________________________

6. INFORMATION ON MILITARY SERVICE:
HAVE YOU BEEN IN THE MILITARY SERVICE? YES [ ] NO [ ]
IF SO,ANSWER THE QUESTIONS BELOW:
SERVICE NUMBER:__________________________________________________________________

TYPE OF DISCHARGE:________________________________________________________________
DATES OF SERVICE:__________________________________________________________________
INFORMATION ON ANY SERVICE CONNECTED INJURIES OR DISABILITY IF ANY:___________________

3

PERSONAL INJURY INTAKE FORM
__________________________________________________________________________________

PERCENTAGE OF DISABILITY:___________________________________________________________

PRESENT CONDITION OF SERVICE CONNECTED INJURY OR DISABILITY: _________________________
__________________________________________________________________________________

DO YOU RECEIVE PAYMENTS FOR SERVICE CONNECTED INJURIES? YES [ ] NO [ ]
IF SO, DETAILS______________________________________________________________________

7. INFORMATION ON PRIOR CLAIMS AND LAW SUITS
DO YOU HAVE ANY PRIOR CLAIMS OR LAW SUITS ? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
DATE: ____________________

NATURE OF CLAIM: ____________________

YOUR OPPONENT DETAILS: __________________________________________________________
RESULT: ___________________________________________________________________________

6. PRIOR POLICE RECORD
DO YOU HAVE ANY PRIOR CRIMINAL BACKGROUND? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
PROVIDE DETAILS ON THE DATE, PLACE, COURT NAME, TYPE OF CHARGE AND OUTCOME: ________
__________________________________________________________________________________

8. PRIOR DISABILITY CLAIMS
DID YOU HAVE ANY DISABILITY CLAIMS? YES [ ] NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
INFORMATION ON THE WORKERS COMPENSATION CLAIM:_________________________________
DATE OF INJURY:___________________________________________________________________
4

PERSONAL INJURY INTAKE FORM
DETAILS ON PAYMENTS IF ANY:________________________________________________________
__________________________________________________________________________________
INFORMATION ON ANY OTHER DISABILITY PAYMENTS:_____________________________________
__________________________________________________________________________________

9. PRIOR PHYSICAL EXAMINATIONS
DID YOU HAVE PHYSICAL EXAMINATION FOR ANY PURPOSE DURING THE LAST FIVE YEAR? YES [ ]
NO [ ]
IF SO, ANSWER THE QUESTIONS BELOW
DATE:_______________________________ PLACE________________________________________
NAME OFDOCTOR __________________________________________________________________
PURPOSE_________________________________________________________________________
( employment, promotion, insurance, selective service, armed forces, etc)

10. PRIOR ACCIDENT AND INJURIES
DID YOU HAVE ANY PRIOR ACCIDENTS OR INJURIES ? YES [ ] NO [ ]
IF SO, PROVIDE INFORMATION ON THE DATE, PLACE, NATURE OF THE ACCIDENT ________________
__________________________________________________________________________________
__________________________________________________________________________________

11. ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE
HAVE YOU EVER BEEN TREATED FOR ALCOHOLISM, DRUG ADDICTION, AND VENERAL DISEASE? YES [
] NO [ ]
IF SO, PROVIDE THE DETAILS:__________________________________________________________
__________________________________________________________________________________

12. PRIOR ILLNESS OR DISEASE
DID YOU HAVE ANY PRIOR ILLNESS OR DISEASE? YES [ ] NO [ ]

5

PERSONAL INJURY INTAKE FORM
IF SO, PROVIDE THE DETAILS
DATE___________________ NATURE OF ILLNESS:_________________________________________

DURATION:________________ TREATED BY:____________________________________________
NAME AND ADDRESS OF THE HOSPITAL:_________________________________________________
__________________________________________________________________________________

13. TROUBLE WITH EYES OR EARS
DO YOU NOW, OR HAVE YOU EVER HAD TROUBLE WITH EYES OR EARS: YES [ ] NO [ ]
IF SO, PROVIDE THE DETAILS
__________________________________________________________________________________
__________________________________________________________________________________

14. RADIOACTIVE SUBSTANCES AND ASBESTOS
HAVE YOU EVER WORKED WITH RADIOACTIVE SUBSTANCES OR ANY OTHER SUSTANCE ALLEGED TO
CAUSE ANY DISEASES? YES [ ] NO [ ]

15. INFORMATION ON HEALTH INSURANCE DENIAL
HAVE YOU EVER BEEN DENIED OF HEALTH INSURANCE? YES [ ] NO [ ]
IF SO, BY WHICH COMPANY AND REASON FOR DENIAL:_____________________________________
_________________________________________________________________________________

16. INFORMATION ON ACCIDENT
DATE OF ACCIDENT: _________________________________________________________________
LOCATION OF ACCIDENT:____________________________________________________________
NAMES OF OTHER PEOPLE INVOLVED IN THE ACCIDENT/INJURY, THEIR ADDRESS AND TELEPHONE
NUMBER:
1. ___________________________________________________________________________
__________________________________________________________________________
2. __________________________________________________________________________
6

PERSONAL INJURY INTAKE FORM
__________________________________________________________________________
3. __________________________________________________________________________
__________________________________________________________________________
4. ___________________________________________________________________________
__________________________________________________________________________
HAVE YOU MISSED ANY TIME FROM WORK AS A RESULT OF YOUR INJURY? YES [ ] NO [ ]
IF SO, LIST THE DATES YOU WERE UNABLE TO WORK:
FROM: ___________________

TO: ____________________________

FROM: ___________________

TO: _____________________________

17. LIST OF WITNESSES
1. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________
2. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________
3. NAME: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
TELEPHONE NO: ____________________________________________________________________
RELATIONSHIP: _____________________________________________________________________

18. INFORMATION ON THE INJURY
STATE ALL INJURIES KNOWN TO BE A RESULT OF THE ACCIDENT: ___________________________
_________________________________________________________________________________
_________________________________________________________________________________

7

PERSONAL INJURY INTAKE FORM
LENGTH OF TIME CONFINED TO BED: ________________________________________________ ___
LENGTH OF TIME CONFINED TO HOUSE: ________________________________________________
STATE PRESENT CONDITIONSINCLUDING SCARS, DISABILITIES, DEFORMATIES, DISCOMFORTS, ETC.,
DUE TO THE INJURIES: _____________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________

19. INFORMATION ON THE TREATMENTS
LIST ALL PHYSICIANS, NURSES, THERAPISTS, CHIROPRACTORS, SURGEONS, OR OTHER HEALTH
CAREPROFESSIONALS YOU HAVE SEEN FOR YOUR INJURIES
1. NAME/ TITLE____________________________________________________________________
ADDRESS__________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:_______________________________________________________
NATURE OF CARE____________________________________________________________________
__________________________________________________________________________________
DATE OF DISCHARGE: ______________________________________________________________
2. NAME/ TITLE____________________________________________________________________
ADDRESS_________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:______________________________________________________
NATURE OF CARE__________________________________________________________________
__________________________________________________________________________________

8

PERSONAL INJURY INTAKE FORM
DATE OF DISCHARGE: _______________________________________________________________
3. NAME/ TITLE____________________________________________________________________
ADDRESS__________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
TELEPHONE NUMER:_______________________________________________________________
DATES OF VISIT OR ADMISSION:______________________________________________________
NATURE OF CARE__________________________________________________________________
________________________________________________________________________________
DATE OF DISCHARGE:________________________________________________________________

20. INFORMATION ON SETTLEMENT OFFERS:
HAVE YOU RECEIVED ANY SETTLEMENT OFFERS FOR THIS INJURY? YES [ ] NO [ ]
IF SO, PROVIDE THE INFORMATION BELOW
DATE OF SETTLEMENT OFFER: _______________________________________________________
AMOUNT OF THE SETTLEMENT OFFER: $________________________________________________
NAME, ADDRESS AND TELEPHONE NUMBER OF THE COMPANY OR THE PERSON WHO OFFERED YOU
THE SETTLEMENT:_________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________

21. INFORMATION ON THE DRIVER LICENSE
DRIVER’S LICENSE:_______________________________________________________________
DRIVER’S REGISTRATION:___________________________________________________ ______
CAR MODEL AND TYPE: ____________________________________________________ ______
INSURANCE COMPANY: ___________________________________________________________
ADJUSTER AND TELEPHONE NO.:_______________________________________________

9

PERSONAL INJURY INTAKE FORM
CLAIM/POLICY

NO.:_______________________________________________________________

22. INFORMATION ON HEALTH INSURANCE:
__________________________________________________________________________
__________________________________________________________________________

23. CLIENT’S INSURANCE INFORMATION
DOES CLIENT OR ANYONE IN CLIENT’S HOUSE HAVE AUTO INSURANCE? YES [ ] NO [ ]
IF YES, STATE NAME AND ADDRESS OF INSURANCE OWNER:_________________________________
_______________________________________________________________________________
_______________________________________________________________________________
INSURANCE OWNER’S LICENSE: _______________________________________________________
INSURANCE OWNER’S CAR REGISTRATION: ____________________________________________
INSURANCE COMPANY: _____________________________________________________________
ADJUSTER AND TELEPHONE NO.:_____________________________________________________
CLAIM/POLICY NO.: _______________________________________________________________

24. DEFENDANT AND INSURANCE COVERAGE INFORMATION (VEHICLE WHICH STRUCK CLIENT)
NAME: _________________________________________________________________________
ADDRESS:________________________________________________________________________
__________________________________________________________________________________
TELEPHONE NO.: __________________________________________________________________
DEFENDAT’S LICENSE: ______________________________________________________________
DEFENDANT’S VEHICLE REGISTRATION: _________________________________________________
VEHICLE MODEL AND TYPE: __________________________________________________________
INSURANCE COMPANY NAME AND ADDRESS:_____________________________________________
10

PERSONAL INJURY INTAKE FORM
________________________________________________________________________________
________________________________________________________________________________
ADJUSTER NAME ADDRESS AND TELEPHONE NO.: ________________________________________
________________________________________________________________________________
________________________________________________________________________________
CLAIM/POLICY NO.: _______________________________________________________________
DEFENDANT ATTORNEY NAME ADDRESS, AND TELEPHONE NUMBER:__________________________
__________________________________________________________________________________
_________________________________________________________________________________

25. FACTS OF CASE
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________

11

PERSONAL INJURY INTAKE FORM
FOR OFFICE USE ONLY:
ATTORNEY NOTES AND CHRONOLOGY OF EVENTS:
ATTORNEY NOTES
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________________

CHRONOLOGY OF EVENTS
DATES

EVENT

1._______________________

________________________________________________.

2. _______________________

________________________________________________

3._______________________

________________________________________________

4._______________________

________________________________________________

5._______________________

________________________________________________

6._______________________

________________________________________________

7._______________________

________________________________________________

8._______________________

________________________________________________

12

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