Personal Injury Client Intake Questionnaire

This Personal Injury Client Intake Questionnaire is a ready-to-use form that helps law firms gather critical case details at the start of a representation. It is organized into easy-to-follow sections covering personal details, accident facts, treatment, insurance, and lost wages — making it simple for clients to complete and staff to review.

Sections include:

• Client identity and contact information

• Accident date, location, and police report details

• Medical treatment history and current providers

• Insurance carriers (both parties) and claim status

• Employment information and wage loss

• Open-ended questions for case-specific details

Formatted in Microsoft Word, this editable form can be printed, emailed, or converted to a fillable PDF. Includes a placeholder for your law firm’s letterhead and branding.