Personal Injury Questionnaire

Please complete the following form in its entirety. The more details you are able to provide Moore-Faust the better. You can save your progress and resume filling out the form if you need.

For any documents, medical records, photos, etc., that support your answers, please email them to the administrative assistant assigned to your case.

Please enable JavaScript in your browser to complete this form.

- Step 1 of 11

Name *

First

Last

Email *

Phone

Save and Resume Later

Please check each problem you have experienced due to your injury in the incident, regardless of whether you still have the problem or not.

(Some problems are listed more than once. Please check a symptom every time it is listed).

Head

Headaches in temples or around eyes
Migraine headaches
Cluster headaches
Headaches across back of head
Memory impairment, loss, or forgetfulness
Concentration difficulty
Speech dysfunction/slurring of words
A loss of consciousness
Dizziness
Pain or pressure above or behind eyes
Vision problems
Hissing, ringing in ear
Hearing problems
Ear pain w/o infection
Dental injury such as chipped teeth/cracked teeth
Nerve injury to the face or scalp
Scarring to the face or scalp
Balance, disequilibrium difficulties
Clicking, popping sounds in jaw joints
Clenching and/or grinding teeth at night/in sleep
Inability to open and close mouth smoothly
Jaw deviates to one side
Discomfort of cheeks, chin along jaw-line
Nose Injury

Neck and Back

Pain in upper back
Pain in middle back
Pain in lower back
Lack of mobility in upper back
Lack of mobility in middle back
Lack of mobility in lower back
Pain/lack of mobility in across the shoulder blades
Scarring

Arms and Hands

Lack of mobility in the shoulder joints
Catching or popping in the shoulders
Difficulty in lifting your arms above your head
Shoulder pain
Arm & finger tingling, numbness, falling asleep, loss of strength or pain
Lack of mobility or pain in the elbows
Lack of mobility or pain in the wrists
Difficulties with your hands or fingers
Scarring

Legs and Feet

Knee pains
Lack of mobility in the knees
Catching or popping in the knees
Ankle pains
Lack of mobility in the ankles
Catching or popping in the ankles
Pain, tingling, numbness, or falling asleep feelings radiating down from the low back and hip area into the backs of the legs
Sciatica
Difficulties with your feet or toes
Scarring

Psychological and Emotional

Nervousness
Insomnia
Chronic tiredness
Fainting spells
Loss of interest in activities
Social withdrawal
Personality changes
Nonspecific anxiety
Nonspecific depression
Sleep disturbances
Irritability/anger
Appetite/weight changes
Loss of energy, fatigue

Please list any other injuries you suffered in this incident:

Save and Resume Later

Please describe how this incident happened: *

Please describe how this incident has affected your life, including whether the impact in your description was temporary or is permanent: *

Save and Resume Later

Employment

Describe what difficulties you have encountered at work.

For example, if you have had to alter you work schedule, had to change your workstation due to your injuries, had to limit or modify your work duties, have fellow employees help with your work duties, change occupations, etc.

Describe any work modifications or accommodations that have been made for you.

Save and Resume Later

Hobbies, activities, things with your friends and family

How your injuries have impacted things you enjoy doing?

Explain what other day-to-day activities you have not been able to perform.

For example, yard work, auto repair, gardening, home maintenance, cooking, cleaning, laundry, shopping, caring for children, etc.

Save and Resume Later

motor If and

Pyschological and Emotional

How this incident and your injuries have created any psychological or emotional distress for you?

Save and Resume Later

Other Impacts

Please describe any other impacts on your life that you would like to share with us to better understand the effects of the incident.

Save and Resume Later

Prior and Subsequent Injuries

Have you ever been involved in any other motor vehicle collisions?

Please list the approximate dates of all other collisions:

If you were injured in any of these other motor vehicle collisions, please briefly describe your injuries and medical care required (including ER visits): (copy)

Have you ever had any workers' compensation claims?

Please list the approximate dates of all claims:

If you had any workers' compensation claims, please briefly describe your injuries and medical care required (including ER visits):

If you have been injured in any other incidents, such as falls, fights, sports or other recreational injuries, please list the approximate date, describe the injury, and medical care received (including ER visits):

Save and Resume Later

Wage Loss Verification Checklist

If you were working on the date you were injured, indicate the approximate number of hours you worked per week.

Regarding your employer on the date you were injured, please state:

Company Name

Company Phone

Company Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Job Title

You Job Duties

Your Supervisor's Name

Rate of Pay

How often are you paid?

Are you still employed there?

If no, please explain why.

Save and Resume Later

Employment questions continued

Did you lose any time from your job because of your injuries?

If so, how much?

Does this include time missed to attend doctor’s appointments?

If so, how much?

Did you lose any commission/salary/wages because of the time lost from your job?

If so, how much?

Did you have to use sick leave time or other benefits (such as vacation or comp. time) because of your injuries?

If so, how many hours?

At any time since the date you were injured, have you been unable to perform the duties required of your job?

Following your injury, did any of your doctors advise you not to return to work, or to return only to light duty work?

If so, which doctor(s)?

Did your doctor(s) tell you how long it would be before you could return to your old job?

Yes
No
Unknown

If so, how long?

Did your doctor(s) provide a written work release, stating you could not work for a period of time?

If so, which doctor and how long were you released from work?

If you were released from work by your doctor(s), have you since returned to work?

If so, when?

Did you return to the same job?

If not, please explain why and what job you returned to.

Were you paid by your employer for the time you missed from work?

If you returned to your old job, did you find you were unable to complete the physical requirements of the job and, therefore, were forced to quit your job or were fired?

Have you received any Workers' Compensation, insurance payments, or other type of benefits since the date you were injured?

If so, please list them:

If you were not employed on the date you were injured, were you looking for work?

Yes
No
Not applicable

Except for the fact that you were injured, would you have accepted work if it had been offered to you?

Is there any reason why your employer will not or cannot provide us with written verification of your loss of wages and/or benefits? If yes, please explain in detail:

If you have suffered a loss of income and/or benefits due to your injuries, please inform your supervisor or other person (such as the bookkeeper or payroll clerk) that we will require an accounting, in writing, of your rate of pay, the number of hours you would have worked per week had you not been injured, and the amount of wages and/or benefits you have lost to date, because of your injuries.

Save and Resume Later

Please describe any other damages or impacts on your life due to this incident that further explain what you have been through that have not previous described.

Custom Captcha *

What is 7+4?

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *