CLIENT IN TAKE-Vehicle Accide4nt

Date of Intake: ____/________/______        Time of Intake: _____:____

Date of Accident: _________ Time:             

1. Name: First Name: ___________________Last Name ________________________ Middle: ________________          

        Date of Birth: __________________________ Age: ____________ Place of Birth: ____________
        Client was:  Driver: ______________
                            Passenger: [__}  [___]
                            Pedestrian  [___]
                            Other [____] Specify: _____ __________
     
       Home Address:

       Street Address:  __________________  Unit/Apt: No: __________
       City:     ____________________________________
       State:  __________________      ZIP Code:  __________________
       Country: __________________

      Telephone: Home:  _______________________     
      Emergency Contact: _______________________  
      Emergency Contact: _______________________  
      Business:  _______________________   
      Message Phone: __________________ Fax: _________________Cell: _______________________
      EMAIL: ___________________________@__________________________

2. . Marital Status:  Single: ______Date of Marriage: ___________
                                  Single: ______Living With ___________
                                  Married: ______Date of Marriage: ___________
                                  Divorce: _______Year Divorced: _____________
                                  Spouse Name: ________________________________________    
                                  Children:   ____________________

3. Education:: Grade School Name: _________________________
                                  Address: ______________________
                                 Year Attended
                         High school: ____________
                                 Address: ______________________
                                 Year Attended
                        Vocational: ___________
                        College: Degree_______

4. Occupation:

    Type of Business or Occupation:
    Employee Identification number:
    Supervisor Name: ___________:
    Social security Number:  _________ -- _________ --________

7. Employment:

    Name of Employer: _____________________________________
    Tel: ____________________________
    Employer Address
    Title or Position:                                  
    Last Day Worked Prior To Injury: ___________________________

8. Insurance:
    Employee Group Insurance:
    HMO ________________________
    Private:
    Homeowners:

9. Injury: Whiplash: __________________
                Soft Tissue: ______________________
                Part of Body Injured:
                Back: Upper Back: _____________  Lower Back: ____________
                Neck: _____________[    ] Joints____________
                Leg: ___________________ [    ] Joints____________
                Foot: _________________ [    ] Joints____________
                Arm: ____________[    ] Joints____________
                Wrist: _______________________ [    ] Joints____________
                Hand: _____________________ [    ] Joints____________
                Fingers:________________________[    ] Joints____________
                Other: ________________________________________________
                            _______________________________________________
                Broken Bone: __________________
                Fracture: Hairline_ __________
                Compound: _____________
                Part of Body Injured: Upper Back: _____________ 
                Lower Back: ____________
                Neck: ________
                Leg: ___________________
                Foot: _________________
                Arm: ____________
                Wrist: _______________________
                Hand: _____________________ Fingers:
                Other: ________________________________________________
                _______________________________________________
                Amputation: __________________
                Fracture: Hairline_ __________
                Compound: _____________
                Part of Body Injured: Upper Back: _____________ 
                Lower Back: ____________
                Neck: ________
               Leg: ___________________
               Foot: _________________ Arm: ____________
                                                      Wrist: _______________________ Hand: _____________________ Fingers:
                                                       Other: ________________________________________________
                                                                   _______________________________________________
10: Factors Contributing to injury:

    a. what did you body do upon impact:___________________________
     b. Did your body strike any part of car;_________________
     c. Were you wearing sat belt: _______________________________
         Type of seat belts: Lap ---Shoulder

11. Limitations of Activity:  

    Unable to work:
    Full Time work:                     
    Part time work:
    Limitation of Motion:
    [  ] Can't walk [  ] Can't squat [  ]can't bend  [  ] can't stretch ____________
    [  ] can't sit for long periods of time
    Hobbies: Client unable to: Walking [  } Jogging [  ] Running [  ] Tennis [  ] Swimming  Exercise [

12. Medications: Over The counter:  Aspirin:         Tylenol: _________________________
                             Prescription:     
                             Doctor Prescribing Medication: ___________________________

11. Pre Existing Injuries:

        Nature of Pre Existing Injuries:
        Cause of Pre Existing Injuries:
        Date of Pre Existing Injuries:
        Complete Recovery of Pre Existing Injuries:

12. Aggravation of Injury:

        How made worse:________________________________

13. Medical Information

    Name of Doctor: Name: _____________Telephone: _________________________

    Hospital: Name: 

14.Location of Accident:

        Street Name _____________________________
        City: _____________________________________ State: ___________________________
        Intersection of ________________________ Street and ______________________________Street

        Traffic controls:   Traffic Light ______
                                     Stop Sign: ____________Two way Stop _____________Four way top
                                     Yield Sign: ____________ Curve Warning:
                                     Speed Sign _________Speed Indicated ______MPH
                                     Other Traffic sign
                                     There was no Traffic Control
                              
       
Time of Accident __________________

Traffic conditions: light ____ Heavy ____Moderate -----Bumper to bumper ________ Slow_____ Stop and Go_____

Road Condition:

Weather Conditions:

Clear day [   ]  Cloudy [   ] Ran [    ] Sunny [    ] Heavy Rain Snow [   ] Windy [   ]

Vehicle Involved In accident

Client Car:  Make: ____________ Year: __________ Model: _________ Color ___________ License Plate: ____________
                   Legal Owner: Name: _______________ Address: ________________________ Tel:
                   Registered Owner: Name: _______________ Address: ________________________ Tel:

Defendant Car:  Make: ____________ Year: __________ Model: _________ Color ____________ 
                   Legal Owner: Name: _______________ Address: ________________________ Tel:
                   Registered Owner: Name: _______________ Address: ________________________ Tel:

Other  Car 1:  Make: ____________ Year: __________ Model: _________ Color ____________
                  Legal Owner: Name: _______________ Address: ________________________ Tel:
                  Registered Owner: Name: _______________ Address: ________________________ Tel:



Streets On Which Cars Were tRaverl89ing:

Client traveling  on _______________Street/Avenue/boulevard/ Direction North ____ South ___ East ___ West:_____

Driver:

Passengers:

    1. ________________________________________________________ Tel: ________________________________
    Address:
    Age: ____________________________________________ Gender:  {   }Male Female [___]
       

Seating Positions:

Passenger: _________________ : Location


Photographs

Medication:

Witnesses:

Passengers:

Police Investigation

    Did Police arrive
    Was a report made:

Traffic Citation: Person:

    Violations

  

Documents Need:  Receipts: ____________________________________
Wage Stubs: ____________________________________________________

Name of Person Doing Intake: ______________________

Action Take:

Case Accepted: Acceptance Letter Sent:_______________ Dater Sent:   
Retainer Agreement Sent:
Case Not Accepted: Refusal Letter Form: ____Sent:_______________ Date Sent:   

Instructions to: Secretary____________ Paralegal___________________________
Prepare:
                Form Complaint ___________________________
               
 

   
    .

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