1 [Interview Form - Personal Injury Case] 1. Personal and Family History Full name Present home address Present business address Home phone Business phone 2. of Injury or Accident Location of accident s and addresses (if known) of other people involved 3. List all other names by which you have ever been known. Include marital and maiden names, nicknames and aliases. 4. List the addresses where you have resided during the past 10 years. Indicate the period of time at each residence, including dates: 5. of Birth 6. Are you presently married? of marriage of marriage Full name of spouse Have you ever been divorced or legally separated? Give details.
2 7. List the names, ages and addresses of everyone including children who are dependent on you for support, and your relationship to each: Age Relationship 8. Employment History Social Security Number Most recent employer Employer s address Beginning date Ending date Job description Beginning pay rate Ending pay rate Did you miss time from work as a result of your injuries? List the dates you were unable to work: From: To: Reasons for leaving job: Employer prior to one last listed Employer s address Beginning date Ending date Job description Beginning pay rate Ending pay rate Did you miss time from work as a result of your injuries? List the dates you were unable to work: From: To: Reasons for leaving job:
3 Employer prior to one last listed Employer s address Beginning date Ending date Job description Beginning pay rate Ending pay rate Did you miss time from work as a result of your injuries? List the dates you were unable to work: From: To: Reasons for leaving job: [Have client bring in Income Tax Returns for prior years.] 9. Education List your educational level (high school, college, graduate school, professional training) Do you have any special job training? 10. Military Background Have you been in the military? Give service number Type of discharge s of service Have you had any service-connected injuries or disabilities? Give details. Percentage of disability Present condition of service-connected injury or disability Do you receive payments for service-connected injuries? Have you ever been rejected for military service because of physical, mental or other reasons? If so, explain
4 11. Prior Claims and Lawsuits (Our adversaries will inquire about your history of legal claims and lawsuits. It is important that you disclose your complete history to us. It is not fatal if you have been involved in prior legal actions. You won t be penalized by a court or jury if the claims were reasonable and genuine.) List every claim you have ever made for personal injury or property damage. Give details. Against whom Nature of claim Against whom Nature of claim Against whom Nature of claim 12. Police Record (The defense will investigate your background. We must be prepared against any unfavorable evidence that is uncovered. Evidence of prior criminal acts might be used against you at trial, no matter how mitigating the circumstances.) List all prior arrests. State the date, place, charge and result: 13. Workers Compensation Have you ever made a claim for workers compensation? What was your injury? was the date of your injury? Are you presently receiving payments? Explain Who is handling your workers compensation action? Are you receiving disability payments from any source other than workers compensation? Explain
5 14. Prior Physical Examinations List every physical examination you have ever had during the last 10 years for any purpose, including employment, promotion, insurance, selective service and armed forces. of doctor of doctor of doctor of doctor of doctor 15. Prior Accidents and Injuries (Failure to mention other accidents or injuries can undermine a lawsuit, no matter how trivial they may seem.) List all prior incidents, whether they resulted in a claim for damages or not. State the date, place, nature of the accident and extent of your injuries.
6 16. Illness or Disease (We must know about all prior illnesses, either before or since your accident. This is particularly true if there is any connection with your present physical complaints. The defendant will have access to a complete history of your past physical condition as well as your veteran?s records, insurance records, and medical and hospital records.) and address of hospital and address of hospital and address of hospital and address of hospital and address of hospital Do you know, or have you ever had trouble with Ears Eyes Have you ever worn glasses? Artificial eye? Hearing aid?
7 Have you ever worn a brace or back and neck support? Have you ever worked with radioactive substances, asbestos or any other substance alleged to cause diseases, such as cancer? Have you ever been denied life or health insurance? If so, by which company and why? Have you ever been treated for alcoholism, drug addiction or venereal disease? 17. The Injury State all injuries known to be a result of the accident Length of time confined to bed Length of time confined to house State present physical condition, including scars, disabilities, deformities and discomforts due to the injuries 18. List all physicians and surgeons you have seen
8 19. List all nurses, therapists and health care professionals that you have seen 20. Calendar information Has client been served with pleadings? is response due? Statute of limitations expires Enter case and upcoming activity in office calendar system. Attach to this interview form: 1. Medical Authorization 2. Fee Agreement
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