Client Interview Information Questionnaire
Complete Name
Present Address
City County State Zip Code
Telephone No________ _______-________ ________ _______-
Area Code Home Area Code Work
_______________ _____________________
Age Date of Birth Place of Birth
(a) Married Single Divorced Widow/Widower
(b) Spouse's name
Address
City County State Zip Code
(c) Names and Ages of Children-if none, please indicate:
Name Address Phone No.
(a) Father and Mother:
Name Address Phone No.
Name Address Phone No.
(b) Person who will always know your whereabouts:
Name Address Phone No.
(a) Your occupation:
(b) Present Employer:
Name
Address
Phone No.
(c) Rate of Pay:
Hourly, Weekly, or Yearly (specify)
(d) Social Security No.:
Education:
(a) High school: Name:
Address:
Dates of Attendance:
Subject Matter Concentration:
Date of Graduation:
(b) College:
Name:
Address:
Dates of Attendance:
Major/Minor:
Date of Graduation:
Degree:
Injury:
(a) Date of injury:
(b) Time of injury:
(c) Place of injury:
Address
City County State Zip Code
Area in building, e.g., floor number, stairway, elevator
If auto accident, streets or highways and direction
Witness(es):
(a) Full names and addresses of all persons who saw injury:
Name Address Phone No.
Name Address Phone No.
Name Address Phone No.
(b) Names of all persons who were on scene after accident:
Name Address Phone No.
Name Address Phone No.
At time of injury did you have any of the following, and if so, state what:
(Yes or No)
(a) Disability
(b) Disease
(c) Infirmity
Doctor(s) you had before injury:
(a) Family doctor:
Name and Address
(b) Specialist:
Name and Address
(c) Chiropractor
Name and Address
Before the injury did you ever make a claim for personal injury? (Yes or No)
If yes, state:
(a) When:
(b) Where:
City County State
(c) Reason for Claims:
(d) Type of injury or claim:
(e.g., auto, industrial, workman's comp., injury at home)
(e) Date and type of resolution:
Have you ever been injured before this accident?__________ (Yes/No)
If yes, state:
(a) Where:
(b) When:
(c) Nature of injury:
(d) Doctor(s):
Name and Address
(e) Hospital(s) or clinic(s):
Name and Address
Have you been injured since this accident?____________ (Yes/No)
If yes, state:
(a) Where:
(b) When:
(c) Nature of injury:
(d) Doctor(s):
Name and Address
(e) Hospital(s) or clinic(s):
Name and Address
Have you had hospitalizations, operations, or significant medical treatment in the past 10 years?____________ (Yes/No)
If yes, state:
(a) When:
(b) Where:
(c) For what reason:
(d) Doctor(s):
...
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