Injury Interview Form – Fill Out and Use This PDF

The Injury Interview Form, developed by Matthew D. Kaplan, LLC, is a detailed questionnaire designed to gather comprehensive and precise information from individuals who have suffered personal injuries. It covers a wide array of categories from the date and details of the accident, insurance information, to the nature of the injuries and their impact on daily activities. For those seeking legal assistance, completing this form thoroughly can significantly aid your case. Ensure your information is accurately represented by clicking the button below to fill out the form.

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Injury Interview Form PDF Details

When individuals find themselves navigating the aftermath of an accident, the process of documenting their experience and injuries is crucial for legal proceedings. The Personal Injury Client Interview Form by Matthew D. Kaplan, LLC, is designed to capture comprehensive details about the incident in question, aiming to ensure that all relevant information is meticulously recorded. This form requires clients to provide specific information about the accident, such as the date, time, and location, as well as personal data including their name, contact details, and social security number. Furthermore, it delves into the specifics of the accident's circumstances, asking for descriptions of weather and road conditions, a diagram of the accident, details of all vehicles involved - including insurance information, and an account of the accident's dynamics. Additionally, it covers the aftermath in terms of injuries and wage loss, requesting detailed descriptions of the client's injuries, the impact on their daily activities, and the financial toll of wage loss due to the inability to work. The form acts as a foundational document that plays a pivotal role in establishing the nuances of the case, ensuring that clients and legal representatives have a thorough understanding of the accident's impact on the client's life.

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

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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.

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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!

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Injury Interview Form – Fill Out and Use This PDF

Injury Interview Form PDF Details

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