PERSONAL INJURY QUESTIONNAIRE

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LAW OFFICES OF Daniel H. Alexander A PROFESSIONAL LAW CORPORATION 901 Bruce Rd., Ste. 230 Chico, CA 95928 951 Reserve Dr., Ste. 100 Roseville, CA 95678 (800) 530-4529 (530) 891-8000 Fax (530) 891-8040 www.dalexander.com 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 # Email 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

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

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

Please diagram how the accident happened: 4

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

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

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

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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