Injury Intake Form Template: Incident Details & Insurance

Injury Intake Form Template

[Firm / Clinic / Organization Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Email: [Email Address]

1. Personal Information

Full Legal Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Primary Phone: [Phone Number]

Secondary Phone (optional): [Phone Number]

Email Address: [Email Address]

Preferred Contact Method: [Phone / Email / Text / Other]

2. Emergency Contact

Emergency Contact Name: [Name]

Relationship to You: [Relationship]

Phone Number(s): [Phone Number(s)]

3. Incident Information

Type of Incident (check or describe):

• Motor vehicle accident (may include DUI-related)

• Workplace injury

• Slip-and-fall / trip-and-fall

• Sports / recreational injury

• Assault or violence

• Other: [Describe]

Date of Injury: [MM/DD/YYYY]

Approximate Time of Injury: [HH:MM a.m./p.m.]

Location of Incident (street, business, job site, city, state):

[Location description]

Was this incident reported to anyone at the time? [Yes / No]

If Yes, to whom (police, supervisor, property owner, other):

[Name / Title / Agency]

4. Description of What Happened

In your own words, briefly describe how the incident occurred:

[Free-text narrative]

Were there any vehicles, equipment, substances, or hazards involved (for example, another car, a wet floor, broken step, defective tool)?

[Free-text description]

Did you fall, get struck, twist, or experience another type of impact? Describe:

[Free-text description]

5. Police, Incident, or Claim Reports

Did police, security, or another authority respond? [Yes / No]

If Yes, specify:

• Agency / Department: [Name]

• Officer / Contact Name (if known): [Name]

• Report or Incident Number (if known): [Number]

Have you already filed a claim with any insurance company? [Yes / No]

If Yes, list:

• Insurance Company Name: [Name]

• Claim Number: [Number]

6. Injury Details

Check and describe every body part injured in this incident:

Head / Face / Neck: [Description or “None”]

Shoulder / Arm / Elbow / Wrist / Hand: [Description or “None”]

Back / Spine / Torso: [Description or “None”]

Hip / Leg / Knee / Ankle / Foot: [Description or “None”]

Other Areas: [Description or “None”]

Type(s) of Injury (check all that apply and describe):

• Bruise / Contusion – [Description]

• Cut / Laceration – [Description]

• Sprain / Strain – [Description]

• Suspected fracture / fracture – [Description]

• Concussion / head injury – [Description]

• Soft tissue injury – [Description]

• Burn – [Description]

• Other: [Describe]

Current Symptoms (pain, stiffness, weakness, numbness, headaches, dizziness, etc.):

[Free-text description]

7. Pain Level and Functional Impact (Initial)

On a scale of 0–10 (0 = no pain, 10 = worst pain imaginable), rate your pain today:

Pain Score Today: [0–10]

Activities currently made difficult by your injury (check all that apply and describe):

• Walking or standing

• Sitting for long periods

• Lifting or carrying items

• Bending or reaching

• Driving or using transportation

• Sleeping

• Household chores

• Work or school tasks

• Hobbies / sports / exercise

• Other: [Describe]

Details:

[Free-text description]

8. Medical Treatment to Date

Did you receive any treatment immediately after the incident? [Yes / No]

If Yes, check and complete:

• First aid at the scene – Provided by: [Name/Role]

• Ambulance / EMS – Transported to: [Hospital/Facility Name]

• Emergency room visit – Facility: [Name] – Date: [MM/DD/YYYY]

• Urgent care / clinic visit – Facility: [Name] – Date: [MM/DD/YYYY]

List all medical providers you have seen for this injury so far (doctors, hospitals, therapists, chiropractors, etc.):

Provider 1:

Name: [Name]

Specialty: [Specialty]

Facility: [Name]

City/State: [City/State]

First Visit Date: [MM/DD/YYYY]

Most Recent Visit Date: [MM/DD/YYYY]

Provider 2:

Name: [Name]

Specialty: [Specialty]

Facility: [Name]

City/State: [City/State]

First Visit Date: [MM/DD/YYYY]

Most Recent Visit Date: [MM/DD/YYYY]

[Add additional providers as needed.]

Treatments received (check all that apply):

• Physical examination and advice

• X-rays

• CT scan / MRI / other imaging

• Prescription medication

• Over-the-counter medication

• Physical therapy

• Chiropractic treatment

• Injections

• Surgery or procedure

• Counseling or psychological support

• Other: [Describe]

9. Current Medications and Restrictions

Current medications you are taking for this injury (name and dose, if known):

[Free-text list]

Have any doctors given you written work or activity restrictions? [Yes / No / Not sure]

If Yes, describe:

[Free-text description]

10. Insurance Information

Health Insurance

Health Insurance Company: [Name]

Policy or Member Number: [Number]

Group Number (if any): [Number]

Auto Insurance (if motor vehicle involved)

Your Auto Insurance Company: [Name]

Policy Number: [Number]

Other Driver’s Insurance (if known):

Company: [Name]

Claim or Policy Number (if known): [Number]

11. Employment / School Information

Are you currently employed? [Yes / No]

If Yes:

Employer Name: [Name]

Job Title: [Title]

Employer Address: [Address]

Normal Work Schedule (before injury): [Schedule]

Have you missed work because of this injury? [Yes / No]

If Yes:

Dates missed: From [MM/DD/YYYY] to [MM/DD/YYYY or “ongoing”]

Approximate number of full days missed: [Number]

Approximate number of partial days (left early/arrived late): [Number]

Are you currently a student? [Yes / No]

If Yes, School Name: [Name] and impacts on attendance or performance: [Description]

12. Prior Injuries or Conditions

Before this incident, had you ever injured the same body part(s)? [Yes / No]

If Yes, describe:

• Previous injury or condition: [Description]

• Approximate date(s): [Dates]

• Whether you had recovered before this new incident: [Describe]

13. Witnesses and Additional Documentation

Were there any witnesses to the incident? [Yes / No / Not sure]

Witness 1:

Name: [Name]

Phone / Email: [Contact]

Witness 2:

Name: [Name]

Phone / Email: [Contact]

Do you have any of the following (check all that apply):

• Photos or videos of the scene

• Photos of your injuries

• Police or incident reports

• Medical records or bills

• Employer or HR reports

• Other documents: [Describe]

14. Impact on Daily Life

Describe how this injury affects your daily life and activities at home, work, or school:

15. Representation and Consent

Have you previously consulted with or hired any attorney about this injury? [Yes / No]

If Yes, provide name and contact information:

[Name, Firm, Phone, Email]

Have you previously signed any releases, settlements, or waivers related to this incident? [Yes / No / Not sure]

If Yes or Not sure, briefly describe:

[Free-text description]

16. Declaration and Signature

Please read carefully before signing.

I, [Your Full Name], certify that the information provided in this Injury Intake Form is true and complete to the best of my knowledge and belief. I understand that this form is used for intake and evaluation purposes only and does not by itself create an attorney–client, doctor–patient, or any other professional relationship.

I understand that I should review any important legal or medical decisions with a licensed attorney or healthcare provider.

Signature: _______________________________

Printed Name: [Your Full Name]

Date: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]