PERSONAL INJURY QUESTIONNAIRE
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- Allison Mills
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1 LAW OFFICES OF Daniel H. Alexander A PROFESSIONAL LAW CORPORATION 901 Bruce Rd., Ste. 230 Chico, CA Reserve Dr., Ste. 100 Roseville, CA (800) (530) Fax (530) dan@dalexander.com CLIENT INFORMATION: PERSONAL INJURY QUESTIONNAIRE Name: Spouse How did you hear about our office (phone book?) or who referred you: List any other names you have used or been known by other than shown above, stating when and why you used such other name(s): Current Address: Phone: Home # Business # Drivers License # Date of Birth: Cell # Message # Address: Social Security #: Occupation / Employer: Duties: Dates not worked due to accident: (YOUR) Insurance Companies: Auto Policy #: Claim # Health Policy #: Auto Policy Coverage: Your Insurance s Adjuster: 1
2 DEFENDANT S INFORMATION: Name: Address: Phone # Driver s License #: Defendant s Insurance Company: Auto Policy #: Claim # Other (ex: Home Owners): Policy #: Insurance Coverage: Defendant s Insurance Adjuster: OTHER ACCIDENTS AND INJURIES: Your attorney must know all your past accident and injuries. If your attorney does not know of your past accident / injury history he can not properly handle your case. One will not be penalized by the courts for past claims or lawsuits if they were reasonable. Failure to mention other accidents and/ or injuries can undermine your lawsuit, no matter how trivial they may seem. Therefore, please list every accident and / or injury, whether it resulted in a claim for damages or not. State the DATE, PLACE, NATURE OF INCIDENT AND / OR INJURIES: If none, so state: POLICE RECORD: It is the law in California that if a person has a criminal record, no matter how long ago, or what the circumstances, that may be brought up at trial. The defense will make a complete investigation of your background, and we must be prepared against development of unfavorable evidence. Therefore, please list ALL ARRESTS, if any, and state the DATE, PLACE, CHARGE, and RESULT OF THE ARREST: 2
3 NATURE OF ACCIDENT: Date of Accident: Time of Day: Location of Accident: If it was an AUTO ACCIDENT please state: Who was the DRIVER of your vehicle: Who were PASSENGERS OF YOUR VEHICLE: Number of People in your vehicle: Number of people in other vehicle: In what City did the accident occur: County: Name of the street, road or highway: What direction were you traveling: North South East West Were you struck from: Behind Front Left Side Right Side Accident Report by: (ie: CHP / Police) Report #: DETAILS OF THE ACCIDENT: Names, addresses, phone numbers of Witnesses: Circumstances/Type of Accident: In your own words please describe the accident: 3
4 Please diagram how the accident happened: 4
5 PRIOR INJURIES: Did you have any physical complaints before the accident: YES NO If so, please list the type of injury, your treating physician of that injury, and type of treatment: INJURIES FROM ACCIDENT: Where you taken from the accident by ambulance / flight care: YES NO PLEASE DESCRIBE HOW YOU FELT: DURING the accident: IMMEDIATELY after the accident: The NEXT day: What treatment did you receive as a result of the accident (doctors / physical therapy / hospitals / ambulance): Medical Provider 1: Medical Provider 2: Medical Provider 3: Medical Provider 4: Medical Provider 5: Medical Provider 6: Other Medical Providers: 5
6 What are your present CONDITIONS and SYMPTOMS: CHECK THE SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT: ( ) Headaches ( ) Tensions ( ) Cold Feet ( ) Stiff Neck ( ) Cold Chest ( ) Nervousness ( ) Driving Anxiety ( ) Bleeding ( ) Nausea ( ) Diarrhea ( ) Upset Stomach ( ) Loss of Memory ( ) Irritability ( ) Cold Sweats ( ) Cold Hands ( ) Back Pain ( ) Fever ( ) Dizziness ( ) Constipation ( ) Loss of Taste ( ) Loss of Smell ( ) Loss of Vision ( ) Depression ( ) Numbness ( ) Numbness in Fingers ( ) Numbness in Feet ( ) Sleeping Problems ( ) Ringing Ears ( ) Sharp Pain in Arm/Feet ( ) Loss of hair ( ) Shortness of Breath ( ) Buzzing in Ears ( ) Flush Face Do you have pain that radiates / travels from your neck into your arms and hands? Do you have pain that radiates / travels from your back into your butt, legs or feet? Please indicate below where you have pain by placing an X at pain locations: 6
7 ACTIVITIES SINCE THE ACCIDENT: Please list all of your daily activities and special interests (hobbies) that you have NOT been able to perform since the accident due to your injuries. (Include such things as yard work and recreational activities): Did you have to hire someone to take care of your chores (ie. yard work, house work, shopping, business, etc.) YES NO If you did hire someone, please list their name / address / and amount paid to date: GENERAL BACKGROUND: Your attorney must know about your background. Your educational and physical history may have an important bearing upon your case. Education High School: College / Vocational Training: WORK BACKGROUND: Where you employed at the time of the accident? YES NO Employers name, address and phone number: What was your job title and duties: How many hours a week were you working before the accident? How many hours a week are you working since the accident? What was your rate of pay (hourly amount, etc.): Have you remained at the same job? YES NO 7
8 INCOME LOSS If you have missed work, give the dates you missed work so far: Did you lose wages for the period of time you missed work? YES NO If so, please list your hourly rate: monthly rate: Total amount of wages lost so far: If you have changed jobs or are no longer employed, please give a summary of your reason for leaving your employer at the time of the accident: If you have changed jobs since the accident please list your present employer / job, rate of pay, and hours worked: Please list your employment records as far back as possible: PROPERTY DAMAGE: Do you attribute any loss of or damage to a vehicle: Yes Do you have photos of the damage to your vehicle: Yes No No (if not, please take photos immediately) Make and Model of Vehicle: Who owned vehicle: Location of Damage on Vehicle (ie front, back, etc.): Has a written estimate for repair been done? Yes No Amount of Estimate for Repair: Who Prepared the Estimate: Was the vehicle repaired? Yes No Who repaired the vehicle: What was the cost of repair: Do you still have the vehicle? Yes No 8
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SOUTH TEXAS BONE & JOINT NEW PATIENT INFORMATION (PLEASE PRINT) DATE: PATIENT S NAME EMAIL DATE OF BIRTH AGE M/ F SOCIAL SECURITY # MAILING ADDRESS PERMANENT OR TEMPORARY CITY, STATE, ZIP CODE (AREA CODE)
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)
Name: Date of Birth: Sex: Office: Date:
Patient Information Name: Date of Birth: Sex: Office: Date: Address: City: State: Zip: Social Security Number: Home Phone: Cell Phone: Email: May we leave a message? Email? Martial Status Emergency Contact
Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:
Patient Name: Today s Date: Preferred Language: Date of Birth: Age: SSN: Race: Ethnicity: Home Phone: Cell Phone: Work Phone: Best contact phone number should we need to reach you about your treatment:
Multi-Specialty Musculoskeletal Pain Relief Center
Name Social Security # Age Birthdate Date Home Tel Address City State Zip Work Tel Cell Number Email Address Marital Status: M S W D # Children Spouse s Name Your Occupation Emergency Contact Name and
Advanced Diabetes & Endocrine Medical Center, P.A.
PATIENT REGISTRATION FORM Primary Care Physician Referring Physician Patient s Name: (Last) (First) (Middle) Address: Marital Status: S / M / D / W City/State/Zip: Social Security: Male / Female Date of
. Assignment of Insurance Benefits
Pulmonary & Critical Care Associates, L.L.C. P l e a s e P r i n t Referred By: Dr. / Friend_ PATIENT INFORMATION (Name) City, State, & Zip:_ Number (home): EMPLOYMENT INFORMATION Employer: City, State
Caritas Medical Center, LLC
Caritas Medical Center, LLC KIDNEY DISEASE AND HYPERTENSION SPECIALIST 105 NORTH PARK TRAIL SUITE 300 STOCKBRIDGE, GA 30281 OFFICE: 678 284 0800 FAX: 678 284 9299 WWW.CARITASMED.COM DR. LEO OVADJE DR.
Patient Registration Form
Arizona Retina Institute Patient Registration Form Patientʼs Name:" " " " " " " Todayʼs Date:" /" / Patientʼs Social Security#" " " " " Date of Birth:" /" / Gender: Male " Female Marital Status: Single
PAYMENT POLICY: Payment or partial payment is required on the day of visit.
Patient Information Date Patient Name (First) (M.I.) (Last) Date of Birth SSN Gender Male Female Transgender-Male Transgender-Female Marital Status Race Ethnicity Preferred Language Patient Address City
PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
MOTOR VEHICLE ACCIDENT HISTORY
MOTOR VEHICLE ACCIDENT HISTORY Email : Name: Date: Male Female DOB: DL #: Home #: Married Single Social Security #: Cell #: Widowed Divorced Address: City: State: Zip: Occupation: Employer: Work #: Address:
SunDance Behavioral Resources, LLC Adult Registration & History Form
SunDance Behavioral Resources, LLC Adult Registration & History Form Name: Sex: M / F Date of Birth / / Age: Address: Social Security #: Occupation: City State Zip Employer: Best phone number for appointment
Patient Registration Form
Patient Registration Form PATIENT INFORMATION Please Print Last Name: First: M.I. Mailing Address: City: State: Zip Code: Date of Birth: Gender: M F Married Single Widowed Divorced Separated Partnered
Signature: Print Name: Date:
~ PLEASE PRINT CLEARLY ~ LAST ADDRESS FIRST MI HOME PHONE SOCIAL SECURITY # EMPLOYER WORK PHONE DATE OF BIRTH JOB/ PROFESSION: CELL PHONE MARITAL STATUS SPOUSE S SPOUSE S SOCIAL SECURITY # (If under spouse
Advanced Therapy Solutions
Advanced Therapy Solutions Patient First Name Address City State Zip Social Security # Date of Birth / / Sex: M or F Drivers License # Marital Status: Single, Married, Divorced Email Address: @ Home Phone
Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:
Date: Patient Health Information Patient Name: First Middle Last Nickname Date of Birth: Age: Sex: Male Female Referring Physician: Family Physician: City: City: What is the main reason for your visit?