Personal Injury Questionnaire
First Name
Last Name
Address
Email
DOB
Date of accident or injury
Location of accident or injury (city, county, and state)
Describe how the accident happened.
State each part of your body that was injuried.
Did you go to the hospital or emergency room immediately following the accident.
Yes
No
State the name of every doctor you have seen for your injury. Include in your response the diagnosis(s) and treatment(s) given by each provider.
Do you have permanent injuries? If so, please state each such injury and the medical provider who informed you the injury is permanent.
Have you been given an impairment rating? If so, please state the rating and the medical provider who gave it.
State the total amount of medical expenses you have incurred to date.
Have you lost income or expect to lose income in the future because of the accident and injuries? If so, please state the total of lost income to date and the total expected lost future income if known.
Do you expect to incurr additional medical expenses and are you still being treated for your injuries?
Did you give a statement to anyone at the time of the accident or afterwards? If so, please state the name of the person you gave the statement to and what you said.
List the name, address, and phone number for every person that witnessed the accident or injury.
State the name, address, and phone number, if known, of person or persons that caused the accident or injury.
Did any other person at the scene of the accident, including the person that casued the accident, give a statement about what happened? If so, please state everything that person said.
Submit
Cancel
Please fill in all the required fields before submitting this form.
×
