Client Interview And Investigation Sheet

Date of Interview:

Interviewed by:

Injury Type:

other

Client Contact:

Name:

Date of Birth:

Address:

Phone:

Can Text:

YesNo

Email:

Client info:

Married:

Kids/Ages:

Current Occupation:

Current Employer:

Can/Are You Still Working?

Salary Change After Crash:

YesNo

How Much (per week or month):$

Previous Occupation:

Who is you primary care physician?

Name of facility/Doctor:

Contact Info:

Address:

Insurance:

Health Insurance?

YesNo

Medicare/Medicaid?

YesNo

Company:

Policy #:

Auto Insurance?

YesNo

Company:

Policy #:

Claim # (if created already):

Have you given statement to any insurance company (if so, explain)?

If Homeowners Claims:

Whose Property Did Injury Occur On:

Client’s Homeowner Insurance?

YesNo

Company:

Policy #:

Other Party Homeowner Insurance?

YesNo

Company:

Policy #:

The Crash / Property Damage:

Police Report Made:

YesNo

Report #:

Agency?

Statement given to police?

YesNo

If yes, Explain:

How many vehicles/units involved?

Was client’s vehicle totaled/drivable?

Was other’s vehicle totaled/drivable?

Client’s vehicle damage?

Other’s vehicle damage?

Point of impact on client’s vehicle?

Other property damage (barriers/wildlife/city property)?

Any passengers in client vehicle?

YesNo

How many?

Any passengers in other vehicles?

YesNo

How many?

Any cameras nearby that client aware of/noticed?

YesNo

If yes, explain

Client description/story of crash/incident:

Client driving for rideshare:

YesNo

If yes, what stage:

Other driving for rideshare:

YesNo

If yes, what stage:

Witnesses:

1) Name:

Phone:

a. Relation

2) Name:

Phone:

a. Relation

3) Name:

Phone:

a. Relation

Any cameras from nearby businesses or police pod that may have captured the incident?

If yes,

Name of the establishment:

Address:

Bodily Injury:

Position / activity before impact (neck turned/hands on wheel/drinking water/etc)?

Position / activity during impact (hit head/wrist buckled/etc)?

Feelings/emotions/pain immediately after crash:

Symptoms, pain and current injuries:

Hobbies/Activities/Clubs:

How has this impacted daily life / activities client cannot do or has pain with / etc:

Things not able to do anymore with friends, spouse, kids anymore (if applicable):

Have your injuries affected your spouse or kids?:

Treatment:

EMS Transport?

YesNo

Agency?

Transported to which hospital?

List Prior/Current Treatment Facilities:

1) Facility:

DOS:

2) Facility:

DOS:

3) Facility:

DOS:

4) Facility:

DOS:

5) Facility:

DOS:

Do you consent for our firm to order all of your treatment records and billing, which may include signing on client’s behalf?

YesNo

Is client able to receive and send records to our office once they are mailed to client’s address?

YesNo

PRIORS:

Any Prior Crash/Fall/Injury:

YesNo

Was a insurance claim made ?:

YesNo

If yes, when? With which insurance company? Did you hire a lawyer? When was this claim resolved?

List Prior Injury When:

1) Injury:

When:

Type (fall/MVC/other):

2) Injury:

When:

Type (fall/MVC/other):

3) Injury:

When:

Type (fall/MVC/other):

Underlying / chronic issues (diabetes, high blood pressure, etc):

If yes, any medications?

Any previous surgery / when?

Any prior x-rays/MRIs?

Witnesses:

We will be emailing you an attorney agreement and HIPAA authorization for you to sign and return – do you prefer email or text message. Additionally, we will be sending a reminder document with things to keep in mind throughout this whole process along with a list of items we will need from you. Please review and send the following information:

- Signed Contract and HIPAA Authorization.
- Any Photos (including either vehicle, any injuries, any property damage, or any other information related to this incident.)
- Any Witness Information/Police Information/Police Report.
- Driver License.
- Healthcare and Auto Insurance Cards.
- All Medical Records and Billing

This will all be in our follow up email, and you can respond directly to the email with this information. Are you are treating at a facility? We will make an appointment/refer you to a nearby facility if you would like. Please let us know the best day/time for your initial appointment. You will receive a text with the treatment facility information. Thank you for choosing Owaynat Law Group!

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"My primary goal is to achieve the best possible outcome for our clients in every type of case we handle."

- Mohammad Owaynat, Esq.