Personal Injury Questionnaire
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
E-Mail Address:
Fax:
Date of Accident:

(mm/dd/yy)
Location of Accident:
Did the police respond to your accident?
Yes No
If so, do you have a police report?
Yes No
Were you examined or treated at a hospital emergency room?
Yes No
Were you hospitalized?
Yes No
Did you see a doctor as a result of your injuries?
Yes No
Are you currently under a doctor's care for injuries sustained in this accident?
Yes No
How much time, if any, did you lose from work or school?
Description of Accident:
Describe Your Injuries:
For motor vehicle accidents, describe the damage to the vehicles: