REFERRED BY: __________________ DATE: __________________________ PERSONAL INJURY INTERVIEW SHEET CLIENTS: (1) Date of Birth Name: Age: if a minor: Address: Home Phone: Bus. Phone: (Parents name Marital Status: Name of Spouse: if a Minor) Employer: Job Description: Address: Weekly or Yearly Gross Income: Wage-loss verification forms given to client: Passenger: Driver: (2) Date of Birth Name: Age: if a minor: Address: Home Phone: Bus. Phone: (Parents name Marital Status: Name of Spouse: if a Minor) Employer: Job Description: Address: Weekly or Yearly Gross Income: Wage-loss verification forms given to client: Passenger: Driver: Previous Injury History: (1) (2) Did client make a statement to anyone other than this office? Details: (1) (2) Does client carry medical coverage insurance? Amount: (1) Company: Amount: (2) Company: Automobile Insurance: (1) Company: (2) Company: >>>> 2 Uninsured Motorists Insurance: (1) Company: (2) Company: Clients Vehicle: Type of Vehicle: Year: Owner of Vehicle: Driven from accident scene: Towed by whom: Approximate damage to vehicle: Client advised to obtain two (2) estimates: Client advised to photograph damage: OCCURRENCE Date of Accident: Time: Location: DESCRIPTION PREVIOUS INJURIES: Hospitalization Past 5 Years: Where: When: Doctor: Illness: NAMES & ADDRESSES OF PERSONS WHO WILL HAVE KNOWLEDGE OF CLIENTS CASE: Work-related: Family: Friends: ARE PHOTOGRAPHS ADVISABLE: (car, scar, intersection, cast, etc.) ARE PHOTOGRAPHS ORDERED: NAME AND ADDRESS OF WITNESS: IS INVESTIGATION INDICATED: DATENAME OF INVESTIGATOR: PHONE: ORDERED: WAS THERE ANY DRINKING INVOLVED: WERE POLICE NOTIFIED: WAS POLICE REPORT MADE: CITY: COUNTY: STATE HIGHWAY: OTHER: WERE ANY ARRESTS MADE : DISPOSITION OF HEARING IF KNOWN: >>>> 3DEFENDANTS: Name: Address: State License: Name: Address: State License: Name of defendants insurance carrier or broker: MEDICAL: Attending Doctor: Address: Other Doctors (first aid, consultants, etc.) Address: Nature of Injuries: Hospital: X-rays taken: Where: By whom: DAMAGES: Property Damage: Rep. Bill - Est. Rep. Dec. $ __________________________ X-ray Bill: _____________ Amb: _______________ Hosp. Bill:________ Orthopedic App.: _________ Nursing Care:________ Household Help: _________________________________________ Other: _________________ Lost Time: ___________________ M.D. Bills: _______________________ HAS CLIENT BEEN INSTRUCTED 1. To give no information to anyone other than representative of our office?_________________ 2. To be patient? Case may take three-to-six months before settlement, if any can be effected. If lawsuit, then longer? 3. To forward to this office all bills or receipts for hospital, x-ray, property damage, loss of earnings, and medical reports?