Injury Interview Form – Fill Out and Use This PDF

The Injury Interview Form is a comprehensive questionnaire to fill out following an accident or case of injury. This vital information serves as a helpful reference tool that provides insight into the conditions surrounding the injury and its potential cause. With accurate details and data, experienced professionals can use this form in their analyses for adjudication or investigation purposes. Visually organized and easy to use, the Injury Interview Form helps guide the user through questions pertaining to date and time of incident, location of incident, parties involved, circumstances preceding the injury, witness accounts (if applicable), equipment used, symptoms directly related to injury, discussions leading up to medical evaluation and more.

Get Form Now Download PDF

Injury Interview Form PDF Details

Are you a coach or medical professional who deals with athletes? You know all too well the importance of proper injury management and prevention. To assist in providing quality care for your athletes, creating an effective injury interview form is key to understanding the source of a player's ailment so that the appropriate steps can be taken for accurate diagnosis and treatment. Here we will discuss essential elements of an effective injury interview form, from what questions should be asked, to when they should be administered, to how they need to be accurately completed.

Question	Answer
Form Name	Injury Interview Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	human filliiable legal, interview history filliiable, injury interview form, intake filliiable legal

Form Preview Example

Matthew D. Kaplan, LLC

PLEASE TAKE YOUR TIME IN COMPLETING THIS QUESTIONNAIRE. IT IS VERY IMPORTANT TO

YOUR CASE THAT THIS INFORMATION IS AS THOROUGH AND ACCURATE AS POSSIBLE.

Personal Injury Client Interview Form

DATE OF ACCIDENT:

TIME OF ACCIDENT:

NAME:

TODAY’S DATE:

STREET ADDRESS:

SPOUSE/PARTNER:

CITY, STATE, ZIP CODE:

SOCIAL SECURITY NO:

HOME PHONE #:

DATE OF BIRTH:

WORK PHONE #:

AGE:

CELL PHONE#:

REFERRED BY:

DRIVER OF YOUR VEHICLE

NAME:

POLICY HOLDER:

STREET:

ADDRESS:

CITY, STATE, ZIP CODE:

PHONE #:

PASSENGERS:

DRIVER’S LICENSE #:

DESCRIPTION OF VEHICLE:

LICENSE PLATE NUMBER AND STATE:

INSURANCE CARRIER:

INSURER’S ADDRESS:

ADJUSTER(S) NAME(S):

ADJUSTER(S) PHONE #:

CLAIM # (IF KNOWN)

-IF DIFFERENT-

OWNER’S NAME:

OWNER’S ADDRESS:

OTHER DRIVER

NAME:

POLICY HOLDER:

STREET:

ADDRESS:

CITY, STATE, ZIP:

PHONE #:

PASSENGERS:

DRIVER’S LICENSE#:

DESCRIPTION OF VEHICLE:

LICENSE PLATE NUMBER AND STATE:

INSURANCE CARRIER:

INSURER’S ADDRESS:

ADJUSTER(S) NAMES(S):

ADJUSTER(S) PHONE #(S):

CLAIM # (IF KNOWN):

-IF DIFFERENT-

OWNER’S NAME:

OWNER’S ADDRESS:

ACCIDENT INFORMATION

CITY AND COUNTY WHERE ACCIDENT OCCURRED:

LOCATION OF ACCIDENT:

WEATHER AND LIGHT CONDITIONS:

ROAD CONDITIONS:

POSTED SPEED LIMIT:

DESCRIBE HOW THE ACCIDENT HAPPENED:

DRAW A DIAGRAM OF THE ACCIDENT:

DESCRIBE DAMAGE TO YOUR VEHICLE:

DESCRIBE DAMAGE TO OTHER VEHICLE:

YOUR ESTIMATE OF REPAIR COST:

WERE YOU WEARING A SEAT BELT:

WERE YOU WORKING AT THE TIME:

WERE YOU AWARE OF THE PENDING CRASH:

WERE YOU STOPPED, SPEEDING UP, OR SLOWING DOWN AT THE TIME OF IMPACT:

IF YOUR VEHICLE WAS TOWED, WHO TOWED IT:

NAME OF POLICE AGENCIES AT THE SCENE:

WAS ANYONE CITED:WHAT FOR: WHAT AMBULANCE OR EMT WERE AT THE SCENE:

HOW DID THE PEOPLE LEAVE THE SCENE (E.G., AMBULANCE, THEIR CAR):

LIST ANY WITNESSES, THEIR ADDRESSES, AND PHONE NUMBERS:

	WAGE LOSS


EMPLOYER’S NAME:
EMPLOYER’S ADDRESS:
HOURS NORMALLY WORKED PER DAY:			PER MONTH:
INCOME PER HOUR:		PER MONTH:

DATES UNABLE TO WORK DUE TO ACCIDENT:

TOTAL INCOME LOSS DUE TO ACCIDENT:

DESCRIPTION OF JOB DUTIES:

INJURIES

HEADACHES?	YES	NO
HEADACHES?	YES	NO

DIZZINESS?	YES	NO

NAUSEA?	YES	NO

RINGING IN EARS?	YES	NO

BLURRED VISION?	YES	NO

LOSS OF MEMORY?	YES	NO

JAW PAIN?	YES	NO

CLICKING IN JAW?	YES	NO

EATING/CHEWING DIFFICULTY?	YES	NO

NECK PAIN?	YES	NO

SHOULDER PAIN?

YES

NUMBNESS ANYWHERE?

YES

IF SO, WHERE?

BACK PAIN?

YES

HIP PAIN?

YES

OTHER INJURIES:

IMPAIRED ACTIVITIES

CIRCLE THOSE THAT APPLY:

SPORTS:

BADMINTON	AEROBIC EXERCISES	ARCHERY	WATER SKIING
BOXING	BASEBALL	BASKETBALL	BACKPACKING
FISHING	CARD PLAYING	CAMPING	BASKETRY
HANDBALL	FLYING	FOOTBALL	DANCING
JUDO	GYMNASTICS	HEALTH CLUBS	GARDENING
POTTER	HORSEBACK RIDING	ICE SKATING	HOCKEY
YOGA	JOGGING/RUNNING	PHOTOGRAPHY	KARATE
SOCCER	MOUNTAIN CLIMBING	ROWING/BOATING	RACQUETBALL
WALKING	VOLLEYBALL	SOFTBALL	SKIING
WEIGHT LIFTING	BOWLING	BICYCLING	FENCING
GOLF	HUNTING	PAINTING	RAFTING
SAILING	TENNIS

	DAY TO DAY ACTIVITIES:

DRESSING	BATHING/SHOWERING		BENDING		VACATION
EATING	CAR WASHING		CHURCH		BRUSHING TEETH
IRONING	HOUSE CLEANING		SHOPPING		LAUNDRY
LIFTING	MOVIE GOING		INDIGESTION		DINING OUT
MOVING	SEXUAL RELATIONS		PLAYING W/ CHILDREN		SLEEPING
STANDING	SHAVING		READING		YARD WORK
TRAVELING	WATCHING TV		SITTING		COOKING
SHAMPOOING HAIR	SOCIAL EVENTS		HOLIDAYS

	WORK RELATED ACTIVITIES:
SITTING	WRITING	BENDING		COMPUTER LIFTING
SITTING	WRITING	BENDING		COMPUTER LIFTING
TYPING	STANDING	READING		TELEPHONING

OTHER INJURIES:

PHYSICIANS/MEDICAL FACILITIES

LIST THE NAMES AND COMPLETE ADDRESSES

OF ALL PHYSICIANS AND MEDICAL FACILITIES YOU HAVE SEEN FOR THIS ACCIDENT:

PREVIOUS INJURIES

LIST ALL PREVIOUS INJURIES (INCLUDING ON THE JOB INJURIES):

DATE INJURY PHYSICIAN 1)

PLEASE PROVIDE ANY PHOTOGRAPHS THAT EXIST OF YOUR DAMAGED VEHICLE, THE SCENE OF THE ACCIDENT, AND ANY VISIBLE INJURIES. PLEASE PROVIDE A COPY OF ANY REPAIR ESTIMATES TO YOUR VEHICLE. KEEP AND SEND COPIES OF ALL MEDICAL BILLINGS YOU RECEIVE AND KEEP TRACK OF THE DAYS YOU MISS FROM WORK AS A RESULT OF THIS ACCIDENT.

THANK YOU.

How to Edit Injury Interview Form Online for Free

You are able to fill out filliiable mva online effectively using our PDFinity® editor. The editor is continually improved by our team, getting new awesome features and growing to be better. For anyone who is looking to start, this is what it will require:

Step 1: First, access the pdf tool by clicking the "Get Form Button" in the top section of this webpage.

Step 2: This tool will let you customize almost all PDF files in various ways. Transform it by writing any text, correct existing content, and put in a signature - all readily available!

To be able to finalize this document, be sure you provide the required information in each and every blank field:

1. Whenever filling in the filliiable mva online, be certain to include all of the essential blank fields within the associated area. It will help to hasten the work, enabling your details to be handled without delay and correctly.

intake filliiable legal conclusion process outlined (stage 1)

2. Once your current task is complete, take the next step – fill out all of these fields - DRIVERS LICENSE, DESCRIPTION OF VEHICLE, LICENSE PLATE NUMBER AND STATE, INSURANCE CARRIER, INSURERS ADDRESS, ADJUSTERS NAMES, ADJUSTERS PHONE CLAIM IF KNOWN, IF DIFFERENT, and OWNERS NAME with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Learn how to prepare intake filliiable legal portion 2

People who use this document frequently make errors when completing OWNERS NAME in this area. You need to revise what you type in right here.

3. This 3rd part is usually quite uncomplicated, OWNERS ADDRESS, OTHER DRIVER, NAME POLICY HOLDER, STREET, ADDRESS, CITY STATE ZIP, PHONE PASSENGERS, and DRIVERS LICENSE - all these fields must be filled out here.

intake filliiable legal conclusion process detailed (step 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - DESCRIPTION OF VEHICLE, LICENSE PLATE NUMBER AND STATE, INSURANCE CARRIER, INSURERS ADDRESS, ADJUSTERS NAMESS, ADJUSTERS PHONE S CLAIM IF KNOWN, IF DIFFERENT, OWNERS NAME, OWNERS ADDRESS, and ACCIDENT INFORMATION - to proceed further in your process!

Completing section 4 of intake filliiable legal

5. This form must be finalized with this particular segment. Below you'll see a comprehensive set of fields that have to be completed with accurate details for your form usage to be accomplished: CITY AND COUNTY WHERE ACCIDENT, LOCATION OF ACCIDENT, and WEATHER AND LIGHT CONDITIONS.

intake filliiable legal completion process detailed (portion 5)

Step 3: Reread all the details you have inserted in the blank fields and click on the "Done" button. Create a free trial option at FormsPal and get instant access to filliiable mva online - available inside your personal account. We don't share or sell the details that you enter whenever working with documents at our website.

Injury Interview Form – Fill Out and Use This PDF

Injury Interview Form PDF Details

Form Preview Example

How to Edit Injury Interview Form Online for Free

Injury Interview Form isn’t the one you’re looking for?

Related Documents