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(773) 645-9997

    Client Interview And Investigation Sheet

    Date of Interview:

    Interviewed by:

    Injury Type:

    other

    Client Contact:

    Name:

    Date of Birth:

    Address:

    Phone:

    Can Text:

    Email:

    Client info:

    Married:

    Kids/Ages:

    Current Occupation:

    Current Employer:

    Can/Are You Still Working?

    Salary Change After Crash:

    How Much (per week or month):$

    Previous Occupation:

    Who is you primary care physician?

    Name of facility/Doctor:

    Contact Info:

    Address:

    Insurance:

    Health Insurance?

    Medicare/Medicaid?

    Company:

    Policy #:

    Auto Insurance?

    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?

    Company:

    Policy #:

    Other Party Homeowner Insurance?

    Company:

    Policy #:

    The Crash / Property Damage:

    Police Report Made:

    Report #:

    Agency?

    Statement given to police?

    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?

    How many?

    Any passengers in other vehicles?

    How many?

    Any cameras nearby that client aware of/noticed?

    If yes, explain

    Client description/story of crash/incident:

    Client driving for rideshare:

    If yes, what stage:

    Other driving for rideshare:

    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?

    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?

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

    PRIORS:

    Any Prior Crash/Fall/Injury:

    Was a insurance claim made ?:

    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:

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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.