Personal injury cases seem routine to the outsider, but legal professionals know how hard it is to gather accurate information to get a full picture of the incident. This not only includes data about the actual incident but also about the injuries sustained and the subsequent impacts on your client’s health and personal circumstances.
A personal injury intake form can serve as a valuable shortcut for legal advisers eager to build a strong case and provide the best possible representation. In this post, we’ll show you the questions to ask your client to learn all about their personal injury.
Let’s take a closer look!
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40+ questions to include in your personal injury intake form
Personal information
1. What is your full name?
2. Date of birth
3. Address
4. Phone number
5. Email address
6. Marital status
This can be single, married, or divorced.
7. Do you have any dependents?
If yes, please provide their names, dates of birth, and addresses.
Incident details
8. On what date did the incident occur?
9. At what time did the incident occur?
10. Where did the incident take place?
Please provide the specific location or address.
11. Can you describe how the incident happened?
12. What were you doing at the time of the incident?
13. Were there any hazardous conditions or factors that contributed to the incident?
14. Were there any warning signs or notices present at the incident location?
15. Were there any other people involved in the incident?
If yes, please provide their names and contact information.
16. Did you report the incident to any authorities or organizations?
If yes, please explain to whom and when.
17. Have you taken any photographs or gathered any other evidence related to the incident?
If yes, please upload these files.
Injury information
18. What specific injuries did you sustain as a result of the incident?
19. Which parts of your body were affected?
20. Have you previously experienced any injuries or conditions in the affected areas?
If yes, please describe.
21. Are there any ongoing symptoms or limitations caused by your injuries?
If yes, please provide details.
22. How have your injuries impacted your daily activities and quality of life?
If yes, please provide details.
23. Have you missed any work or school as a result of your injuries?
If yes, please provide dates.
24. Are you experiencing any emotional or psychological effects related to the incident?
If yes, please describe these effects.
Medical treatment
25. Have you received any medical treatment for your injuries?
If yes, please provide details.
26. What diagnoses were given by the medical professionals you consulted?
27. Are you currently taking any medications for your injuries?
If yes, please list them.
28. Do you possess any medical records related to your injury?
If yes, please upload these files.
Insurance information
29. Do you have health insurance?
If yes, please provide the name of your health insurance company.
30. What is your health insurance policy number?
31. Do you have auto insurance?
If yes, please provide the name of your auto insurance provider.
32. What is your auto insurance policy number?
33. Have you already reported the incident to any of your insurance providers?
If yes, which ones and when?
34. Have you filed any claims with your insurance providers related to the incident?
If yes, explain the current status of these claims.
35. Have you incurred any out-of-pocket expenses related to your injuries?
If yes, please list these expenses.
Legal history
36. Have you previously been involved in any personal injury claims or lawsuits?
If yes, please provide details.
37. Are you currently involved in any other legal disputes or claims?
If yes, please describe these claims or disputes.
38. Have you given any statements or testimonies regarding this incident?
If yes, please provide details.
39. Have you signed any documents or agreements related to this incident?
If yes, please provide details on these documents.
40. Have you received any settlements or compensation for injuries related to this incident?
If yes, please provide details.
Authorization and consent
41. Do you authorize our legal team to obtain and review your medical records and other relevant documents related to your injuries and treatment?
42. Do you consent to our legal team contacting your healthcare providers, insurance companies, and other relevant parties to gather information pertinent to your case?
43. Signature
Create a perfect personal injury intake form with Content Snare
Content Snare is a powerful online form builder with a built-in and fully editable personal injury intake questionnaire. This form contains all the questions listed above — you can use our template as-is, or customize it to better suit your clients and cases.
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