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]

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]

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]

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]

Bruise / Contusion – [Description]

Cut / Laceration – [Description]

Sprain / Strain – [Description]

Suspected fracture / fracture – [Description]

Concussion / head injury – [Description]

Soft tissue injury – [Description]

Burn – [Description]

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]

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

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]

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]

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

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]

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]

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]