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New Client Form

Date of Interview:

Date of Loss:

A. Information About Client

Date Of Birth:

If client is a minor or living at home, parents’ names and employers

If Client Has Children

B. Employment History

Did You Miss Any Work Because Of This Accident?

If Working, Has Your Employer Ever Placed You On “light Duty” Of Accomodated You In Another Way? YesNo

C. Educational Background

High School

Graduated

Graduated

College / University

Business School

Technical School

Other

D. Criminal Background

Have You Ever Been Charged With Or Convicted Of A Criminal Offense?

Have You Ever Been Charged With A Serious Driving Offense Such As A DUI, Hit And Run, Negligent Driving, Etc?

E. Symptoms and Injuries

Physical Symptoms

Concussion:

Periods Of “blacking Out” Or Seizures:

Headaches:

Dizziness:

Nausea:

Loss Of Balance:

Problems With Coordination Of Hands, Feet, Or Legs:

Stuttering Or Slurring:

Changes In The Senses Of Smell Of Taste:

Ringing In Ears:

Blurry Or Double Vision:

More Sensitive To Bright Light And/or Loud Noises:

Fluid In Ears:

Vomiting:

Fatigue:

Jaw Pain:

Clicking In Jaw:

Eating/chewing Difficulty:

Neck Pain:

Shoulder Pain:

Back Pain:

Hip Pain:

Cognitive Problems

Attention Or Concentration (mind Wanders; Easily Distracted; Cannot Keep Focus):

Short-term Memory Loss, “forgetfulness,” Or:

Trouble Learning New Things:

Trouble Remembering Old Things (remote Memory) Finding The Right Word When Talking Understanding What Is Said And/or What Is Read Making Decisions Or Solving Problems:

Planning Or Organization:

Making More Mistakes Than Usual Or Not Catching Your Mistakes:

Slower Speed Of Thinking:

Getting Lost Or Disoriented (even In Familiar Places) Trouble Alternating Attention Or “juggling” Several Things:

At Once:

Disorganized Or Confused Thinking:

Emotional Symptoms

Feelings Of Sadness And Depression:

Crying Spells Or Weepiness:

Suicidal Thoughts Or Intentions:

Decreased Or Increased Emotion (circle One) Low Motivation:

Decreased Or Increased Sex Drive (circle One) Decreased Or Increased Appetite (circle One) Decreased Interest In “fun” Activities Irritability/easily Frustrated:

Feelings Of Anxiety Or Fear:

Impaired Activities

Sports

Aerobic: Exercise

Archery:

Backpacking:

Badminton:

Baseball:

Basketball:

Basketry:

Bicycling:

Boxing:

Bowling:

Camping:

Card Playing:

Dancing:

Fencing:

Fishing:

Flying:

Football:

Gardening:

Golf:

Gymnastics:

Handball:

Health Clubs:

Hockey:

Horseback Riding:

Hunting:

Ice Skating:

Jogging/running:

Judo:

Karate:

Mountain Climbing:

Musical Instruments:

Painting:

Photography:

Pottery:

Racquetball:

Rafting:

Rowing / boating:

Sailing:

Snowboarding:

Snow Skiing:

Soccer:

Softball:

Swimming:

Tennis:

Volleyball:

Walking:

Water Skiing:

Weight Lifting:

Yoga:

Day to Day

Bathing/showering:
Bending:
Brushing Teeth:
Car Washing:
Child Care:
Church Events:
Cooking:
Dining Out:
Dressing:
Eating:
Holidays:
Housecleaning:
Ironing:
Laundry:
Lifting:
Movie Going:
Moving:
Reading:
Sexual Relations:
Shampooing Hair:
Shaving:
Shopping:
Sitting:
Sleeping:
Social Events:
Standing:
Traveling:
Vacations:
Watching Tv:
Yard Work:
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Free Consultation

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