PERSONAL INJURY - CLIENT INTERVIEW - …

1 CLIENT information & INTERVIEW PERSONAL INJURY I. CLIENT information Name: _____ Address: _____ Home Phone: _____ Work Phone: _____ Car Phone: _____ Pager: _____ Date of Birth: _____ Social Security #: _____ Marital Status: _____ Number and Ages of Children: _____ Employer(s): _____ Employer(s) Address: _____ _____ _____ Job Title/Description: _____ Wage/Salary: _____ Prior Work Experience: _____ _____ _____ Educational Background: _____ _____ _____ _____ II. THE INCIDENT Date/Time of incident giving rise to this claim:_____ Location of incident giving rise to this claim:_____ Did the police respond to this incident?

2 _____ Which police department(s)?_____ What, if any, police action was taken?_____ Did you go to a hospital? If yes, which one?_____ How long did you stay at the hospital? _____ Famiglietti & Famiglietti, LLC 145 West Main Street . Drawer 250 . Plainville, CT 06062 P 860-793-9559 . F 860-793-9551 . E . W 12/1/2009 2 What was done for you at the hospital?_____ _____ _____ Have you seen a medical practitioner since the incident giving rise to this claim? If so, please list them: _____ _____ _____ _____ _____ Describe the incident that gave rise to this claim in your own words:_____ _____ _____ _____ _____ _____ What do you remember about how you felt or what you thought during the incident?

3 _____ _____ _____ _____ _____ Who else was involved in this incident? Include addresses if known:_____ _____ _____ _____ _____ _____ What was the weather at the time of this incident?_____ What was the weather before this incident?_____ Have you missed work as a result of this incident?_____ How much work time has been lost?_____ Has your medical practitioner told you that you will miss more time from work?_____ And if so, how much?_____ Have you ever been in an accident before?_____ a. When?_____ b. Where?_____ Famiglietti & Famiglietti, LLC 145 West Main Street . Drawer 250 . Plainville, CT 06062 P 860-793-9559.

4 F 860-793-9551 . E . W 12/1/2009 3 c. Did you receive medical treatment?_____ d. Who treated you, and for what were you treated?_____ _____ _____ What is your medical history? Include all surgeries and injuries:_____ _____ _____ _____ _____ _____ Have you ever been disabled from work or physical activity? If so, provide the details in your own words: _____ _____ _____ _____ _____ Have you ever needed physical therapy? If so, when and why?_____ _____ _____ _____ Have you ever filed a workers compensation claim? If so, when and why? _____ _____ _____ _____ Have you ever filed a claim for disability benefits under any insurance policy or government program.

5 If so, when and why? _____ _____ _____ _____ What are your current physical restrictions? _____ _____ _____ _____ How have your injuries impacted your day to day activities?_____ _____ _____ Famiglietti & Famiglietti, LLC 145 West Main Street . Drawer 250 . Plainville, CT 06062 P 860-793-9559 . F 860-793-9551 . E . W 12/1/2009 4 _____ Has your mood or temperament been effected by your injuries? If so, please describe the changes:_____ _____ _____ _____ What medical expenses have you incurred so far as a result of this incident?_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ GREAT RELIANCE IS PLACED ON THE information YOU PROVIDE.

6 PLEASE REVIEW THIS FORM AND CALL IN ANY CHANGES OR ADDITIONS. IF NEW OR CHANGED information COMES TO MIND, BE SURE TO CALL OR WRITE. THANK YOU.