PERSONAL INJURY QUESTIONNAIRE

DITLEVSON RODGERS DIXON, P.S.

Attorneys at Law

324 West Bay Dr NW, Ste. 201

Olympia, WA 98502

(360) 352-8311 phone

(360) 352-8501 fax

PERSONAL INJURY QUESTIONNAIRE

Name______________________________________ Date of birth: __________________

Address ____________________________________ Soc. Security No. _______________

_____________________________________ Home phone __________________

Employer: __________________________________ Work phone __________________

Email ______________________________________ Cell phone ___________________

Spouse _____________________________________

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INFORMATION ABOUT INCIDENT AND INJURY

Location of accident _____________________________________________________________

Date and time of accident _________________________________________________________

Description of accident ___________________________________________________________

______________________________________________________________________________

Injuries noted at the time of the accident ______________________________________________

______________________________________________________________________________

Responsible party’s name and address _______________________________________________

______________________________________________________________________________

Responsible party’s insurance company ______________________________________________

Policy number and phone number ___________________________________________________

YOUR insurance company ________________________________________________________

Policy number and phone number ___________________________________________________

If car accident, were you the ____ Driver ____ Passenger ____ Pedestrian ____ Other

If car accident, make, model and owner of vehicle in which you were riding __________________

Did police respond? _______ If so, what agency? ______________________________________

Did they issue a citation to any party? If so, to whom? ____________________________________

INJURIES AND MEDICAL TREATMENT RECEIVED

Were you taken by ambulance? If so, what agency ______________________________________

Were you seen in the emergency room? If so, when, and what hospital? ____________________

______________________________________________________________________________

Other treatment providers since accident (provide name, address and phone numbers if possible)

______________________________________________________________________________

Are you still in treatment? ________________________________________________________

What are your current symptoms, if any? _____________________________________________

______________________________________________________________________________

PRIOR MEDICAL/BIOGRAPHICAL INFORMATION

Prior accidents or injuries _________________________________________________________

______________________________________________________________________________

Prior hospitalizations _____________________________________________________________

______________________________________________________________________________

Treating providers last five years:

______________________________________________________________________________

Any other information you think might be helpful to us: _________________________________

______________________________________________________________________________