Personal Injury Questionnaire Template: Claim & Evidence

Personal Injury Questionnaire Template

1. General Information

Full Legal Name: [First, Middle, Last]

Other Names Used (if any): [Maiden / prior names or “None”]

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 / Mail / Text]

2. Case, Claim, and Attorney Information

Type of Incident (check or describe):

• Motor vehicle accident (may include DUI-related crash)

• Slip-and-fall / trip-and-fall

• Premises incident (hazardous condition on property)

• Workplace accident

• Assault or intentional harm

• Dog bite / animal incident

• Other personal injury: [Describe]

Incident Date: [MM/DD/YYYY]

Incident Time: [HH:MM a.m./p.m.]

Incident Location (address or description): [Location]

City / State / Province: [City, State/Province]

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

If Yes, list company name(s) and claim number(s):

[Details]

Do you currently have an attorney for this matter? [Yes / No]

If Yes:

Attorney Name: [Name]

Law Firm: [Firm Name]

Phone / Email: [Contact Details]

3. Description of the Incident

In your own words, briefly describe what you were doing just before the incident occurred:

[Free-text description]

Describe step by step how the incident happened (be as specific and factual as possible):

[Free-text narrative: how you slipped/fell, how vehicles collided, how equipment failed, etc.]

Where exactly did the incident occur? (for example, in a store aisle, at an intersection, on stairs, at a job site):

[Location details]

Were there any hazardous conditions involved? (check all that apply and explain):

• Wet or slippery surface – [Explain]

• Uneven floor, hole, or broken step – [Explain]

• Loose objects or obstacles – [Explain]

• Poor lighting – [Explain]

• Equipment or machinery – [Explain]

• Speeding or unsafe driving – [Explain]

• Other: [Describe]

4. Motor Vehicle Accident Details (If Applicable)

Complete this section only if a motor vehicle was involved.

Your Role: [Driver / Passenger / Pedestrian / Cyclist / Motorcyclist / Other]

Your Vehicle (if any):

Year / Make / Model: [Vehicle]

License Plate and State/Province: [Plate]

Other Vehicle(s) Involved (basic description):

[Example: “2018 blue sedan, rear-ended my vehicle,” “delivery truck turning left,” etc.]

Were you wearing a seatbelt? [Yes / No / Not applicable]

Did airbags deploy? [Yes / No / Not applicable]

Briefly describe how the vehicles collided or how you were struck:

[Free-text narrative]

5. Immediate Aftermath

What did you feel immediately after the incident? (check all that apply and describe):

• Pain – [Where and how did it feel?]

• Dizziness / lightheadedness – [Describe]

• Headache – [Describe]

• Nausea or vomiting – [Describe]

• Numbness or tingling – [Where?]

• Weakness – [Where?]

• Other: [Describe]

Did you report the incident to anyone at the scene? [Yes / No]

If Yes, to whom? (store manager, supervisor, driver, property owner, police, etc.):

[Name / Role]

Was a written incident or accident report prepared (by employer, business, or others)? [Yes / No / Not sure]

If Yes, where and by whom?

[Details]

6. Police, EMS, and Emergency Care

Did police respond to the scene? [Yes / No / Not sure]

If Yes:

Law Enforcement Agency: [Agency Name]

Officer Name(s): [Name(s)]

Report or Case Number (if known): [Number]

Was an ambulance or EMS called? [Yes / No / Not sure]

If Yes, were you transported to a medical facility? [Yes / No]

Facility Name: [Hospital / Clinic Name]

Initial emergency treatment received (brief summary):

[For example: “X-rays of neck and back, pain medication, discharged with instructions.”]

7. Injury and Symptom Details

List every part of your body that was injured in this incident:

[Example: neck, lower back, right shoulder, left knee, head, etc.]

For each body part, briefly describe the pain or symptoms (sharp, dull, aching, throbbing, numbness, etc.):

[Free-text]

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

Average daily pain: [0–10]

Worst pain episodes: [0–10]

Have your symptoms changed since the incident? [Improved / Worsened / Stayed the same]

If changed, describe how:

[Free-text]

8. Medical Treatment History

List all medical providers you have seen for this incident (hospitals, clinics, doctors, therapists, chiropractors, etc.).

Provider 1:

Name: [Name]

Specialty: [Emergency / Primary Care / Orthopedics / etc.]

Facility: [Name]

City / State: [City, State/Province]

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/Province]

First Visit Date: [Date]

Most Recent Visit Date: [Date]

[Add more providers as needed.]

Treatments received (check all that apply and briefly describe):

• Emergency room care – [Details]

• Office visits or check-ups – [Details]

• X-rays – [Body parts imaged]

• MRI / CT scans – [Body parts imaged]

• Physical therapy – [Number of sessions, focus of therapy]

• Chiropractic care – [Frequency, duration]

• Injections (e.g., steroid, pain management) – [Where and when]

• Surgery or procedure – [Type and date]

• Counseling or psychological support – [Brief description]

• Other treatment: [Describe]

Current medications (related to this incident):

Name / dosage / how often you take them:

[Free-text list]

9. Daily Activities and Functional Limitations

Check all activities that are now difficult or painful because of your injuries and explain briefly:

• Walking or standing – [Describe limitations]

• Sitting for long periods – [Describe]

• Lifting, carrying, or bending – [Describe]

• Sleeping or lying down – [Describe]

• Driving or using transportation – [Describe]

• Housework (cleaning, laundry, cooking) – [Describe]

• Caring for children, elderly family, or pets – [Describe]

• Hobbies, sports, or exercise – [Describe]

• Social activities or travel – [Describe]

How has this incident affected your overall mood or emotional well-being?

[Free-text description: anxiety, stress, sadness, frustration, etc.]

10. Employment, School, and Income

Employment status at time of incident:

• Employed full-time

• Employed part-time

• Self-employed

• Independent contractor

• Unemployed

• Student

• Other: [Describe]

Employer or School Name: [Name]

Job Title or Student Status: [Title / “Student”]

Normal work or school schedule before the incident:

[Example: “Mon–Fri, 9:00 a.m.–5:30 p.m.,” “Evenings and weekends,” etc.]

Have you missed work or school because of this incident? [Yes / No]

If Yes, provide details:

• 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]

Have your hours, duties, or pay changed because of your injuries? [Yes / No]

If Yes, explain:

[Free-text description]

11. Prior Injuries, Conditions, and Claims

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

If Yes, describe briefly (including approximate dates and whether you had recovered before this incident):

[Free-text]

Do you have any chronic medical conditions that affect your daily activities? [Yes / No]

If Yes, list conditions (for example, arthritis, back problems, prior surgeries):

[Free-text]

Have you ever filed a prior personal injury, workers’ compensation, or disability claim? [Yes / No]

If Yes, provide a brief description (type of claim and approximate year):

[Free-text]

12. Insurance Information

Health Insurance

Health Insurance Company: [Name]

Policy or Member Number: [Number]

Auto Insurance (if motor vehicle was involved)

Your Auto Insurance Company: [Name]

Policy Number: [Number]

Other Insurance (check and describe if applicable):

• Workers’ compensation

• Disability insurance

• Other liability coverage

• Other: [Describe]

13. Witnesses, Photos, and Documents

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

If Yes, list any known witnesses:

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

• Employer or HR reports

• Medical records or visit summaries

• Medical bills or statements

• Repair estimates or property damage records

• Other documents related to this incident: [Describe]

14. Additional Information

Is there anything else you believe is important for your attorney, insurer, or claims professional to know about this incident or your injuries?

[Free-text narrative]

15. Acknowledgment and Signature

I, [Full Name], state that the information provided in this Personal Injury Questionnaire is true and complete to the best of my knowledge and recollection. I understand that this form is used to help evaluate my potential claim and that I should discuss my legal rights and options directly with a licensed attorney.

Signature: _______________________________

Printed Name: [Full Name]

Date Signed: [MM/DD/YYYY]

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