Section 2.22 Client Interview

• Library: DWI 2014 FORMS

Client Interview Form

Personal

Name:

Address:

Home phone: _______________ Work phone: _______________ Cell phone:

Family

Marital status: Single _____________ Married ______________ Divorced

Spouse’s name:

Children: ____________________ Number: ________________ Ages:

If divorced, amount of child support payments:

Employment

Present employer:

Employer’s address:

Name of supervisor:

How long employed: ____________ Job title:

Job duties:

Requirements to drive in connection with job:

Impact of loss of license in connection with job:

Impact of confinement on job:

Impact of work release sentence on job:

Are you a student? Yes _____ No _____ Need to drive for school:

Name of school:

Driver’s License Status

Current status: Valid _____________ Suspended _____________ Revoked

5- or 10-year denial: ____________

CDL: Yes __________ No __________

Were you driving a commercial vehicle?: Yes __________ No __________

Do you have a school bus operator’s permit?: Yes __________ No __________

Have you ever been issued a limited driving privilege?:

Yes __________ No __________

If yes, when:

Have you ever been convicted of a felony involving a motor vehicle?:

Yes __________ No __________ When

Have you ever had a license revoked for breath test refusal?:

Yes __________ No __________ When

Education

High school: _____________________________________________ Year graduated:

College: _________________________________________________ Year graduated:

Other formal education:

Military

Branch of service: ___________________________________ Years of service:

Type of discharge:

Awards and decorations:

Civic Activities

Church:

Clubs and organizations:

Civic awards and honors:

Prior Alcohol-Related Driving Cases

Number Date Court Disposition Probation

1.

2.

3.

4.

5.

Prior Nonalcohol-Related Cases

Number Date Court Disposition Probation

1.

2.

3.

4.

5.

Health and Physical Condition

Age: ____________________ Height: ____________________ Weight:

Problems with any of the following:

Speech:

Hearing:

Vertigo or inner ear problems:

Dizziness from other causes:

Eyes:

Wear glasses: ______________________ Contacts, hard or soft:

Allergies:

False teeth or retainers:

Back:

Legs:

Knees:

Feet:

Arthritis:

Arms:

Stomach:

Liver:

Bladder:

Lungs or other respiratory problems:

Pulmonary function test: __________ When __________ Doctor

Any other physical conditions affecting balance or coordination:

Medical Care and Medication

Surgeries during your lifetime:

Doctors seen in the last five years:

Were you under a doctor’s care at the time of your arrest?:

Prescription medicines used now:

Doctor who prescribed the medicines:

Over-the-counter medicines used now:

How do the medicines affect you?:

Prescription medicines used at the time of your arrest:

Doctor who prescribed the medicines:

Over-the-counter medicines used at the time of the arrest:

How do the medicines affect you?:

Tobacco Use

Smoking: ___________ Brand: ___________ Menthol: ___________ How much:

Other types of tobacco use: What _________________ How much

Background Events on Date of Arrest

Date: _______________ Day of week: _______________ Time of arrest:

Hours you normally sleep:

Hours you slept the night before your arrest:

Unusual events causing lack of sleep or tiredness:

Events causing stress on the day of your arrest:

Breakfast: _____________ Time: ______________ What:

Lunch: ________________Time: ______________ What:

Dinner: _______________ Time: ______________ What:

Other Food: ____________ Time: ______________ What:

Time you began work on day of arrest or previous day:

Time you ended work on day of arrest or previous day:

Activities on day of arrest or previous day if you did not work:

Activities between end of work and first drink:

Name and address of every place you consumed alcohol on the day or night of arrest:

Were drinks purchased with cash or credit card?:

Record of Drinking

Types of drinks:

Size _______ Draft _______ Pitcher ________ Glass ________ Bottle ________ Can

Single shot __________ Double shot __________ Other

Time you began your first drink:

Time you ended your last drink:

Spacing of drinking:

Time elapsed between last drink and stop by officer or accident:

Any drinks while driving before stop?: ________ What?

How many: _________ Time before stop:

If an accident and you left the scene, any drinks after driving?:

What:

Where:

How many:

Time of each drink:

If an accident, drinks while waiting for tow truck or paramedics:

What: ______________________

How many:

Time of each drink:

If first contact with officer was when the car was stopped, any drinks while stopped:

What: ______________________

How many:

Time of each drink:

Activities at Place of Drinking

Dancing ________ Bowling ________ Pool Darts ________ Golf ________ Boating

Other

Names and addresses of people with you while you were drinking:

Person you talked with last before being stopped:

Vehicle

Do you own the vehicle you were driving?:

If someone else’s vehicle, had you driven it before?:

Description of vehicle:

Anything unusual about or problems with the vehicle?:

Name and address of mechanic:

Working orders regarding repairs to vehicle:

Driving Before Arrest

Route from place of drinking to stop by the officer:

Anything unusual that happened while driving:

How many electric signals or stop signs?:

Road conditions including hills and curves:

Weather conditions: Clear _____ Rain _____ Snow ______ Hail ______ Ice ______ Fog

How many traffic...