West Palm Beach Car accident Client Questionnaire 1-800-HURT-911

West Palm Beach Car accident Client Questionnaire 1-800-HURT-911

Client Questionnaire

Name of Claimant:
First Middle Last
Referring Person:

I. Personal Data

Date of Birth: SSN:
Address:
City: State: Zip Code:
Home Phone: Work Phone:
Cell Phone: Email Address:

Married: • Yes • No If yes, please provide the following information:
Spouse’s Full Name:
Spouse’s Date of Birth:
Date and Place of Marriage:

Children: • Yes • No If yes, please provide the following information:

II. Children

1. Child’s Name:
Address:
Date of Birth: Dependent on you? • Yes • No
If yes, social security number:

2. Child’s Name:
Address:
Date of Birth: Dependent on you? • Yes • No
If yes, social security number:

3. Child’s Name:
Address:
Date of Birth: Dependent on you? • Yes • No
If yes, social security number:

4. Child’s Name:
Address:
Date of Birth: Dependent on you? • Yes • No
If yes, social security number:

Name any other dependents, other than spouse and children, including date of birth and social security number:

III. Education

Highest grade in school:
Name of last school attended:
City and State of last school:

IV. Prior Claims History

Have you ever been involved in any litigation? • Yes • No
If yes, please provide the following information:
Nature and reason for case:
Outcome:

Have you ever filed a Workers’ Compensation claim? • Yes • No
If yes, please provide the following information:
For what type of injury:
Date of claim:
Outcome:

Have you ever been convicted or arrested for a crime? • Yes • No
If yes, please explain:

V. Personal Health History

1. Have you ever smoked cigarettes? • Yes • No
If yes, when, how often and for how long?
2. Do you currently smoke cigarettes? • Yes • No
3. Were you smoking at the time you were diagnosed with the injury indicated above?
• Yes • No
If yes, how often and how much?
4. Do you currently drink alcohol? • Yes • No
If yes, please circle one description: Heavy Moderate Light None
Have you ever been to an AA meeting? • Yes • No
5. Describe your dietary fat intake (circle one): Heavy Moderate Light None
6. Describe your physical activity on a daily basis:

VI. Past Medical History

Please provide the following information:
1. Your prior health status (circle one): Excellent Good Fair Poor
2. Prior health history, including any prior hospitalizations and injuries, including approximate dates:

VII. Treating Physicians

Please provide the name of any and all physicians or facilities that have treated you for 10 years prior to the adverse event up to and including the present time. Please include your primary care physician, internist, cardiologist, vascular surgeon, pulmonologist, neurologist, neurosurgeon, psychologist, psychiatrist, social worker, etc. Please use the back of this paper or additional paper if more space is needed.

Physician Name Specialty Reason for Treatment

Dates of Treatment

Street Address, City, State, Zip Code Telephone Number

Physician Name Specialty Reason for Treatment

Dates of Treatment

Street Address, City, State, Zip Code Telephone Number

Physician Name Specialty Reason for Treatment

Dates of Treatment

Street Address, City, State, Zip Code Telephone Number

Physician Name Specialty Reason for Treatment

Dates of Treatment

Street Address, City, State, Zip Code Telephone Number

Physician Name Specialty Reason for Treatment

Dates of Treatment

Street Address, City, State, Zip Code Telephone Number

VIII. Incident Information

1. Date and Time of Incident:
2. Location of Incident:

3. Did the incident occur within the scope of your employment? • Yes • No
If yes, describe:

4. Did the incident occur within the scope of the responsible party’s employment?
• Yes • No
If yes, describe:

5. Names, addresses, and telephone numbers of any witnesses:

6. Names, addresses, and telephone numbers of persons who will have knowledge of your case:

Work-related:

Family:

Friends:

7. Tell us what you believe happened (Use additional paper, if necessary):

8. Are there any photographs or video of the scene, people, vehicles or anything else?
• Yes • No
If yes, describe:

IX. (Motor Vehicle Case)

1. Do you carry medical payment coverage insurance? • Yes • No
Amount: (1) Company
Amount: (2) Company

2 Your Automobile Insurance:
Amount: (1) Company
Amount: (2) Company

3. Identify the liability insurance carrier and policy number, adjuster and claim number, if known of other driver(s):

4. Your Uninsured Motorists’ Insurance:
Amount: (1) Company
Amount: (2) Company

5. Your Vehicle:
Type of Vehicle: Year:
Owner of Vehicle:
Driven from accident scene: Towed by whom:
Approximate damage to vehicle:

6. Other Vehicle(s) Involved:
Type of Vehicle: Year:
Owner of Vehicle:
Driven from accident scene: Towed by whom:
Approximate damage to vehicle:

7. Where were you in vehicle?

8. Name and address of investigating authority (Police Dept., Sheriff, Highway Patrol, etc.):

9. Did you or the other driver(s) receive any citation? • Yes • No

If yes, explain what (you) (other driver) were cited for:

10. What were the weather and road conditions like?

11. Provide accident report if you have it: • Yes • No
12. Had you or anyone else been drinking or taking drugs to your knowledge? • Yes • No
If yes, describe:

13. How did you leave the scene?

X. (Product Liability Cases)

1. Describe in detail the product that you believe injured you:

2. Who owns the product?

3. Where is the product?

4. Do you have access to the product?
5. How old is the product?

6. Do you or does anyone else to your knowledge have any photographs of the product taken shortly after the incident? • Yes • No
If yes, where are the photographs?

XI. (Premises Liability Cases)

1. To whom was the incident reported?

2. Were any photographs taken of the scene or the cause of the incident shortly afterwards?
• Yes • No
If yes, where are the photographs?

3. What were you wearing, including your shoes?

4. Do you still have your clothing and shoes? • Yes • No

5. Did the incident occur outside or inside?

XII. (Medical Negligence Cases)

1. Name, address and telephone number of every person or entity who you believe was the cause of your injuries or illness and why you believe that.

2. Were any photographs or videotapes taken of you, your treatment or your injuries?
• Yes • No
If yes, where are they?

XIII. Immediate Injury Information

1. What (were) are all of your injuries from the incident? (describe in detail):

2. Name and address of any ambulance service:
3. Name and address of hospital where taken:

XIV. Miscellaneous Information

1. Health Insurance
Do you have full health insurance coverage? • Yes • No
If no, what percentage of your medical bills are paid by insurance? %

Name of insurance carrier:
Address:
Phone Number:
Primary Policyholder:
Policy Number:
Date you started with this insurance carrier:
Prior insurance carrier names and dates with this carrier:

2. Medicare
Do you currently have Medicare? • Yes • No
If yes, date started:

3. Medicaid
Have you ever been on Medicaid? • Yes • No
If yes, date started and date stopped:

4. Do you believe that your doctor would be willing to talk to us about his/her experience and knowledge of your injury? • Yes • No
Comments:

5. If so, do you believe that you should be the first person to contact him/her, or may we have permission to contact your physician first?
Comments:

6. Do you believe that any medical mistakes were made in connection with the diagnosis or treatment of the injury you sustained? • Yes • No
If yes, please explain and include all relevant dates and describe any legal action you have taken:

7. Please list the name(s), complete addresses and telephone numbers of all pharmacies where you had your prescriptions filled for the five years up to and including present:

Name

Street Address

City, State, Zip Code Telephone Number

Name

Street Address

City, State, Zip Code Telephone Number

Name

Street Address

City, State, Zip Code Telephone Number

8. How has the incident/accident affected you? (Use additional paper, if necessary)

9. What things do you like to do?

10. What are your likes and dislikes?

XV. Military History

Have you been in the military service?
If so, give branch of service:
Type of discharge:
Dates of service and discharge:
Have you ever been rejected for military service because of physical, mental or other
reasons?
If so, explain:

Do you have any service-connected injuries or disabilities?
If so, give details:

Percentage of disability:
Present condition of service-connected injury or disability:
Do you receive payments for service-connected injuries?

XVI. Employment History

1. Employer’s Name:
Address:

Title:
Job Duties:
Wages/Earnings:
Dates:
Disability?
If yes, describe with inclusive dates:

2. Employer’s Name:
Address:

Title:
Job Duties:
Wages/Earnings:
Dates:
Disability?
If yes, describe with inclusive dates:

Did you ever lose time from work as a result of the injury you sustained from the incident?
• Yes • No
If yes, give the dates you were unable to work:
Did you lose earnings as a result of being unable to work? • Yes • No
If yes, state the amount of earnings lost: $

XVII. Statute of Limitations

(To be completed by Attorney)

Jurisdiction (County/State):
Jurisdiction Statute of Limitations:
Date of incident or negligence:

Thank you for your patience in completing this confidential questionnaire.