
	MEDICAL AND NEGLIGENCE REVIEW

Accident and Injury Questionnaire

This questionnaire is a part of your confidential attorney-client file. Therefore, it is important and in your best interest to answer all of the questions and material fully and in very great detail. Even if something has occurred around the time of injury or accident and you don’t know if it is relevant please include it. It is easier and more efficient to exclude an irrelevant detail than it is to be surprised by an unknown relevant fact. Take your time, be sure you print and save your answers for your own records and be completely honest for this confidential document. It will help you and us process your claim.

INJURED PARTY INFORMATION


Last Name	First MI
Address
City	State Zip

Phone	Home Work Cell
E-mail

Responsible Party if Injured is Minor or Incapacitated
Name
Address
City	State Zip

Date of Injury
Auto Accident	yes no

ACCIDENT INFORMATION

Date		Time

Location
*Street Address*
*Address (cont.)*
City	State Zip
Traveling To:
Traveling From:
Direction of Travel
Weather Conditions

If You Were Parked/Not Moving Where Were You Located?
Address

Passengers
*Name*
	Injured yes no	Seat Belts yes no
Name
	Injured yes no	Seat Belts yes no
Name
	Injured yes no	Seat Belts yes no

Driver Impairment
Alcohol	yes no
Drugs	yes no
Medical Condition	yes no
Loss of Consciousness	yes no

*Were you issued a citation?*
	yes no
What injuries and disabilities do you have that you feel are caused by the accident?

MEDICAL NEGLIGENCE REVIEW
Phone: (248) 540-4557

E-mail: rjg@medicalnegreview.com

MEDICAL AND NEGLIGENCE REVIEW

Accident and Injury Questionnaire