More examples in Forms/Medical & Injury Forms
Questions for Depositions, Statements, and Trial for Personal Injury Example
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Fill name: Current residence: How long: Residence on date of accident: Age: Marital status (then and now): Children: Employment on date of accident: Where: How long: Duties: Do you recall being involved in an accident on....: Time of day: am/pm Day of week: Who was driving: Where: Passengers: Where were you seated: What happened (narrative): What did you see: Did you know you were going to be hit: Lanes of street: Amount of traffic: Divided highway Parking on sides of street: Which way do the streets run: How fast were you traveling: How fast was the other car traveling: Which direction each traveling: Questions for Depositions, Statements, and Trial Turn signals: Traffic controls: Which part of the vehicles impacted each other: What happened to your car upon impact: Which way did vehicle spin: Where did each stop: What did you do after it stopped: Where did your journey begin: Where were you doing: Purpose of trip: When due to arrive: Lightning: Weather: Slope of street: Alcohol/Drugs: All conversation at the scene: Used horn or other warning device: Skid marks: When did police arrive: Who called: Conversation with police: Radio: Windshield wipers: Windows: Defroster: Child in car: Date of last eye examination: Wearing glasses/contacts: Car phone: Stick shift/automatic transmission: Smoking/eating (hands on wheel): Where was the sun: Wearing sunglasses: Witnesses: Who owned the car: When was the car purchased: Borrowed from owner: Type of vehicle: Where licensed to drive: Since when: Restrictions: License ever suspended or revoked: Describe other car: Mechanical condition of your car: Where and when was it last inspected: What, if anything, happened to your body at the moment of impact: What part of your body came into contact with the vehicle: How did you feel at the moment of impact: Seat belt: Where you injured as a result of the accident: What portion of your body came to your attention at the scene: Investigation of accident: What did you do about your injuries: Emergency Room: How did you get there: Type of pain (sharp or dull, constant or intermittent): What was done for you at ER: Medication: Orthopedic appliances: When did you arrive at and leave the hospital: arrived at am/pm left at am/pm How did you feel the next morning: Did you go back to work that day: Did you go anywhere else for treatment: Why: How did you get there: Purpose of visits: Used ER equipment until first doctor's visit: Family doctor: Who referred: Result of first doctor's visit: What was complained of: What was done on subsequent visits: Describe treatment/therapy: Exercises: Whirlpool: Orthopedic appliances: Where were exercises performed: Did they bring relief: For how long did you see this doctor: How many times (total): How many times per week: What other doctor saw you: Why: Who referred you: Specialists seen: Purpose of visits: Medication - side effects: When was the last medical treatment: How did you feel then: How have you felt since then: How do you feel today: How many days a week do you feel pain - what do you do for it: Did pain lessen at any point in treatment: When (for each injury): Were you ever able to resume normal daily activities: When: Household duties: Sports: Driving: Sleeping: Social activities: Marital difficulties: How did you feel before accident: Prior accidents: How long were you treated: Injuries: How long before accident had you recovered: Later accidents: Next scheduled work after date of accident: Did you go to work: Work schedule: Date that you returned to work: Average weekly wage: Why did you not stay home from work: After you went back to work, was there any limitation because of the accident: Inability to do job: Where you carrying anything: Describe your shoes: Describe your clothing: Which foot slipped: Describe your fall: What parts of your body hit the ground: What caused you to fall: Where were you looking When had you last been to the scene of the accident: Were you aware of the defect that caused your fall: Did you have an alternate route: