Personal Injury Intake Form: Critical Questions to Gather Vital Case Information

Personal injury cases need detailed information to build a strong claim. A good intake form helps lawyers gather key facts from clients. It’s the first step in understanding what happened and how to proceed.

A well-designed personal injury intake form can make or break a case. It captures important details about the accident, injuries, and the client’s background. This information guides lawyers in assessing the claim’s strength and potential value.

Asking the right questions from the start saves time and improves the chances of a successful outcome. The following list offers over 40 essential questions to include in a personal injury intake form. These cover various aspects of the incident and its aftermath, giving lawyers a solid foundation for building their cases.

Client Identification

Gathering accurate client details is crucial for a personal injury case. These questions help establish the client’s identity and provide essential contact information.

Personal Information

Full legal name
Date of birth
Social Security number
Driver’s license number and state of issue
Current address
How long have you lived at your current address?
Previous addresses (if less than 5 years at current address)
Marital status
Spouse’s name (if applicable)
Number of dependents

Contact Details

Home phone number
Cell phone number
Work phone number
Email address
Preferred method of contact
Best times to reach you
Is it okay to leave voicemails?
Is it okay to send text messages?

Emergency Contacts

Name of emergency contact
Relationship to you
Emergency contact’s phone number
Emergency contact’s address
Secondary emergency contact name
Secondary emergency contact’s relationship to you
Secondary emergency contact’s phone number
Secondary emergency contact’s address

Incident Details

Gathering accurate details about the incident is crucial for assessing a personal injury case. These questions help paint a clear picture of what happened.

Date And Time Of The Incident

What was the date of the incident?
What time did the incident occur?
Was it during daylight or nighttime hours?
Were there any weather conditions that may have played a role?
How long after the incident did you seek medical attention?

Location Of The Incident

Where exactly did the incident take place?
Was it on public or private property?
If on private property, who owns it?
Were there any hazardous conditions at the location?
Did you take any photos of the incident scene?
Had you been to this location before?

Cause And Nature Of The Injury

What type of incident caused your injury?
Which body parts were injured?
Did you lose consciousness?
Were you taken to the hospital by ambulance?
Have you received any medical treatment since the incident?
Are you still receiving treatment?
Do you have any pre-existing conditions that were worsened?

Witness Information

Were there any witnesses to the incident?
What are the names and contact information of witnesses?
Did anyone admit fault at the scene?
Did the police come to the scene?
Was a police report filed?
Do you have a copy of the police report?
Did anyone take photos or videos of the incident?

Medical Information

Gathering detailed medical information is crucial for a personal injury case. It helps establish the extent of injuries and supports claims for compensation.

Initial Treatment

When did you first seek medical attention after the incident?
Which healthcare facility did you visit first?
What was the initial diagnosis given by the medical professional?
What treatments were prescribed immediately after the injury?
Did you receive any emergency medical care at the scene of the incident?

Ongoing Treatment Plans

Are you currently under medical care for your injuries?
What types of ongoing treatments are you receiving?
How often do you attend medical appointments related to your injury?
Have any future surgeries or procedures been recommended?
What medications are you currently taking for your injuries?

Medical History Relevant To The Injury

Do you have any pre-existing conditions that may affect your current injury?
Have you had any previous injuries to the same body part?
Were you taking any medications prior to the incident?
Have you ever been treated for similar symptoms before?
Do you have a history of any chronic illnesses?

Healthcare Providers

Who is your primary care physician?
What specialists have you seen for your injury?
Have you been referred to any rehabilitation facilities?
Are you seeing any alternative medicine practitioners?
Have you had any second opinions on your diagnosis or treatment plan?

Legal Aspects

The legal aspects of a personal injury case involve crucial information about prior legal actions, attorneys, and insurance details. These factors can impact the current case.

Previous Legal Actions

• Have you been involved in any previous personal injury lawsuits?

• What was the outcome of your prior legal actions?

• Did you receive any settlements from past injury claims?

• Are there any ongoing legal cases related to your injuries?

• Have you filed for bankruptcy in the past 7 years?

Previously Involved Attorneys

• Have you consulted any other attorneys about this case?

• If yes, what is the name of the attorney or law firm?

• Why did you decide to seek new legal representation?

• Did you sign any agreements with previous attorneys?

• Are there any liens from prior attorneys on your case?

Insurance Information

• What is the name of your health insurance provider?

• Do you have auto insurance? If so, with which company?

• What is your policy number for relevant insurance coverage?

• Have you filed any claims with your insurance company for this incident?

• Has the insurance company offered you a settlement?

• Are you covered under any other insurance policies?

• Do you have copies of all relevant insurance documents?

Financial Implications

Financial details are crucial in personal injury cases. They help determine compensation and damages. Here are key questions to include:

Employment Status

• What is your current employment status?

• What is your job title?

• How long have you been employed at your current job?

• What are your typical work hours?

• Do you have any secondary employment?

• Has your injury affected your ability to work?

• Have you had to take time off due to the injury?

Loss Of Earnings

• What is your average monthly income?

• Have you lost any income due to the injury?

• How much income have you lost so far?

• Do you expect to lose future income because of the injury?

• Has your earning capacity been reduced?

• Have you used any sick leave or vacation time?

• Are you receiving any disability benefits?

Additional Expenses

• Have you paid for any medical treatments out of pocket?

• What transportation costs have you incurred for medical appointments?

• Have you hired any help for household tasks you can’t perform?

• Have you purchased any medical equipment or supplies?

• Have you needed to modify your home or vehicle due to the injury?

• Are there any other expenses related to your injury?

• Do you have receipts for these additional expenses?

Supplementary Questions

Gathering additional details can strengthen a personal injury case. These questions cover witnesses, photos, and other key documents.

Potential Witnesses

Did anyone see the accident happen?
What are the names and contact information of any witnesses?
Did you speak to any witnesses at the scene?
Are there any security cameras that may have recorded the incident?
Did any bystanders take photos or videos of the accident?
Has anyone contacted you about being a witness?
Did police interview any witnesses at the scene?

Photographic Evidence

Did you take any photos of the accident scene?
Do you have pictures of your injuries?
Have you photographed any property damage?
Did you take photos of road conditions, traffic signs, or weather?
Are there pictures of the other party’s vehicle or property?
Do you have photos from before and after the injury?
Have you kept a photo log of your recovery process?

Final Information Verification

The last part of a personal injury intake form should confirm key details and get the client’s sign-off. Here are some questions to include in this section:

• Is all the information provided in this form accurate and complete?

• Do you authorize us to contact the medical providers listed?

• May we obtain your medical records related to this incident?

• Can we speak with your employer about time missed from work?

• Do you give permission for us to discuss your case with insurance companies?

• Have you shared all relevant facts about the accident and your injuries?

• Are you aware that providing false information could harm your case?

• Do you understand that submitting this form does not create an attorney-client relationship?

• Will you inform us promptly of any changes to the information provided?

• By signing below, do you certify that you have read and agree to these terms?

Agreement And Authorization

I authorize [Law Firm Name] to represent me in this personal injury case.
I understand that [Law Firm Name] will receive a percentage of any settlement or judgment as payment.
I agree to cooperate fully with [Law Firm Name] throughout my case.
I allow [Law Firm Name] to access my medical records related to this injury.
I permit [Law Firm Name] to speak with my doctors about my injuries.
I agree not to discuss my case with anyone without first consulting my attorney.
I understand that [Law Firm Name] may withdraw from my case if I fail to cooperate.
I confirm that all information provided in this intake form is true and accurate.
I acknowledge that providing false information may harm my case.
I agree to notify [Law Firm Name] of any changes to my contact information.
I authorize [Law Firm Name] to file a lawsuit on my behalf if necessary.
I understand that [Law Firm Name] cannot guarantee the outcome of my case.

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A good personal injury intake form is key for both lawyers and clients. It helps gather important information quickly. But managing these forms can be time-consuming.

File Request Pro offers a solution. This software makes handling personal injury intake forms easier. Lawyers can create custom forms that fit their needs. It covers all important parts of a case.

A great feature of File Request Pro is automatic reminders. Lawyers don’t need to chase clients for answers.

The system sends reminders on its own. All collected info is safely stored in cloud services like Google Drive.

File Request Pro has an easy-to-use interface. Clients can fill out forms with fewer mistakes. This means less back-and-forth later on.

Using File Request Pro can make the personal injury intake process smoother. It handles paperwork tasks automatically. This lets lawyers focus more on the legal side of things. It’s a modern way to improve service for clients during a tough time.

Key Questions to Include in Your Personal Injury Intake Form