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Injury Intake Form Template
Capture complete injury and incident details at first contact with a clear, claimant-friendly intake form.
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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:
[Free-text narrative]
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]
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Learn more about
Injury Intake Form Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
INJURY INTAKE FORM TEMPLATE FAQ
What is an injury intake form?
An injury intake form is a structured questionnaire used at first contact to gather essential information about an accident or injury. It collects personal details, incident facts, medical treatment, insurance information, work status, and how the injury affects daily life, so that professionals can evaluate the situation and decide next steps.
Who uses an injury intake form?
Injury intake forms are commonly used by law firms, medical clinics, chiropractors, physical therapy providers, insurance companies, and employers. They help organize information for potential personal injury, workers’ compensation, or DUI-related crash cases.
What information should be included in an injury intake form?
A helpful injury intake form usually covers: contact and identification details, incident date, time, and location, how the accident happened, all injured body parts, medical treatment to date, health and auto insurance, employment and wage information, prior injuries, witnesses and police reports, and the impact on daily activities. It should also include a declaration and signature section.
Can this injury intake form be used for car accidents, workplace injuries, or slip-and-fall cases?
Yes. This Injury Intake Form Template is designed to be flexible and can be adapted for motor vehicle accidents (including DUI-related crashes), workplace injuries, slip-and-fall incidents, sports injuries, and other personal injury situations. You can add, remove, or rename sections to match your practice or organization.
Does completing an injury intake form create an attorney–client or doctor–patient relationship?
Not necessarily. Completing an intake form usually allows a firm, clinic, or organization to review your information and decide whether they can accept your case or provide services. It does not by itself guarantee representation, treatment, or benefits. Any professional relationship is typically confirmed separately in a written agreement, retainer, or consent form.
Can AI Lawyer help me prepare or customize an injury intake form?
Yes. AI Lawyer can help you organize and customize this injury intake form for your law office, clinic, or business by suggesting wording, layout, and additional questions. You still decide what information to collect and must follow your local legal, medical, and privacy requirements. This template is for general document organization only and is not legal or medical advice.
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