Client Interview Information Questionnaire

  1. Complete Name

  2. Present Address

    City County State Zip Code

  3. Telephone No________ _______-________ ________ _______-

    Area Code Home Area Code Work

  4. _______________ _____________________

    Age Date of Birth Place of Birth

  5. (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.

  6. (a) Father and Mother:

    Name Address Phone No.

    Name Address Phone No.

    (b) Person who will always know your whereabouts:

    Name Address Phone No.

  7. (a) Your occupation:

    (b) Present Employer:

    Name

    Address

    Phone No.

    (c) Rate of Pay:

    Hourly, Weekly, or Yearly (specify)

    (d) Social Security No.:

  8. 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:

  9. 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

  10. 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.

  11. 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

  12. Doctor(s) you had before injury:

    (a) Family doctor:

    Name and Address

    (b) Specialist:

    Name and Address

    (c) Chiropractor

    Name and Address

  13. 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:

  14. 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

  15. 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

  16. 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):

    ...

Get this document and AI-powered insights with a free trial of vLex and Vincent AI

Get Started for Free

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

Start Your 3-day Free Trial of vLex and Vincent AI, Your Precision-Engineered Legal Assistant

  • Access comprehensive legal content with no limitations across vLex's unparalleled global legal database

  • Build stronger arguments with verified citations and CERT citator that tracks case history and precedential strength

  • Transform your legal research from hours to minutes with Vincent AI's intelligent search and analysis capabilities

  • Elevate your practice by focusing your expertise where it matters most while Vincent handles the heavy lifting

vLex

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT