Client Intake

Step 1 of 4

Date

Referral Source

First Name

Last Name

Street Address

City

State

Zip Code

Phone

Date of Birth

Date of Injury

Employer

Street Address

City

State

Date Started Working for Employer

Employer's Workers' Compensation Insurer (If Known)

Union Job?

If Yes, Local Number

Complete Description of the Injury or Illness (Including All parts of Body & Symptoms)

Current Symptoms

Last Date of Employment

Wages at Time of Injury (Indicate Hours Per Week)

Job Title

Job Duties

How Did the Accident Happen?

How Much Time Standing/Sitting/Walking?

Lifting (What and Up to How Much?)

How Many Hours Per Day/Days Per Week?

Overtime?

Did Accident Occur on Employer's Premises?

If No, Where?

Name of Supervisor

Date of Notice of Injury to Supervisor (How?)

Was an Accident Report Filed?

Name, Address, and Phone Number of Witness(es) to the Accident or Injury and What Did They See

Were You Working for More Than One Employer at the Time of the Incident?

If no, skip to "Disability Dates" on the next page.

If Yes, Name, Address, and Phone Number of Second Employer

Wage Rate of Second Employer

Are You Disabled From Secondary Employment?

When, if Ever, Did the Injury Cause You to Stop Working 2nd Job?

Are You Back to Work with the Same Employer? (2nd Job)

If Yes, Is It Your Regular Job or a Modified Position?

Date of Return to Work and Wage Rate

Current Earnings

Disability Dates

Have You Lost the Use of Any Part of Your Body? (Disfigurement, Scarring, Sight, or Hearing)

Is There Other Litigation Pending In This Case?

Was the Notice of Compensation Payable or Denial Issued?

Did You Sign a Supplemental Agreement or Final Receipt?

Have You Been Receiving Workers' Compensation, Unemployment, or Disability Payments?

If Yes, What Type, How Much, and During What Period of Time?

If You Received Payments, When Did They Stop, If Ever

Have All or Any of Your Medical Bills Been Paid?

What Emergency Room Were You Treated In and On What Date?

Was There a Panel List of Doctors?

Name and Address of All Treating Physicians

Name and Address of All Physical Therapists

Did You Have Any Diagnostic Studies Performed? (X-Rays, MRI, EMG, Cat Scan, etc.) If Yes, When and Where?

Are All of Your Prescription Bills Paid?

Have You Had Any Prior Workers' Compensation Claims or Injuries?

Have You Had Any Accidents, Injuries, or Law Suits Prior to Your Present Work Injuries?

Have You Ever Been Arrested/Convicted of a Crime?

Are You Receiving or Have You Received Any of the Following Benefits or Made Claims for the Following Benefits?

Social Security

Third Party Claim

Child/Spousal Support Liens

Welfare

Short/Long Term Disability

Unemployment

If Yes, Explain

Have You Consulted With Another Attorney Regarding This Matter? If So, When and Who?

Address

City

State

Zip Code

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