Personal Injury Patient Questionnaire

Personal Injury
Patient Information
Patient Name*
Date of Birth

MonthDayYear
Date
Law Office
Date of Injury

MonthDayYear
Date
Attorney
Marital Status

SMW
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Race

American Indian or Alaska NativeAsianBlack or African AmericanChineseFilipinoGuamanian or ChamorroKoreanOther Asian (ex: Hmong, Laotian, Thai)Other Pacific Islander (ex: Fijian, Tongan)SamoanVietnameseWhiteOther RaceDecline to Disclose
Ethnic Background

Not Hispanic or LatinoMexican AmericanDecline to DiscloseHispanic or Latino (please choose below)MexicanUnknownChicanoPuerto RicanOther
Preferred Pharmacy
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Injjury Medical Questionnaire
How did your injury happen?
What body parts were affected?
What actions were taken?
NOTES
Physician/Office Name*

Rows	Associated Symptoms (Pain, Itch, Etc.)	Severity 1	Severity 2	Severity 3	Severity 4	Severity 5	Severity 6	Severity 7	Severity 8	Severity 9	Severity 10
1.
2.
3.
4.
5.

Has your condition improved or continues the same?

ImprovedSameWorse
Do you currently have any complaints or symptoms?*
Does the injury affect your activities of daily living? (Please check the box that applies to you).

Maintaining your personal hygiene (bathing, combing hair etc.)Daily house workDriving a carSleepWork performance
Please explain why the activities mentioned above affect your daily living:*
Has the injury caused any changes to your physical appearance?

YesNo
If you answered yes, has the change caused you any embarrassment?*
In a brief sentence, please indicate how the injury has affected you emotionally and/or physically.*
My General Health is:

PoorFairGoodVery GoodExcellent

Rows	Yes	No
Acne Problems
Chest Rash
Discoloration / Stretch Marks
Dry Skin / Itchy Skin
Recent Illness / Weight Loss / Weight Gain
Eczema
Psoriasis
Skin Cancer
Tuberculosis
Other:

Personal Injury