Assessment – Axident Lawyers

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NAME

PHONE

ADDRESS:

Date of Birth

DO YOU HAVE AN ATTORNEY REPRESENTING YOU RIGHT NOW ON THIS CASE?

YES NO

NAME OF YOUR ATTORNEY

PHONE NUMEBR OF THE ATTORNEY:

WHERE YOU INVOLVED IN THE ACCIDENT YOURSELF?

YES

BRIEFLY DESCRIBE WHAT HAPPENNED:

ARE YOU MALE OR FEMALE?

Male

Female

AGE?

WHAT STATE DID THE ACCIDENT OCCUR IN?

ARE YOU ENQUIRING ON YOUR OWN BEHALF OR SOMEONE ELSE’S BEHALF?

MY OWN

SOMEONE ELSE

IF SOMEONE ELSE, IS THAT PERSON RELATED TO YOU?

YES

N/A

IF SOMEONE ELSE, DID THAT PERSON DIE AS A RESULT OF THE ACCIDENT?

YES

ARE YOU THE SPOUSE OF THE DECEASED?

YES

IF YOUR OWN, WERE YOU INJURED IN THE ACCIDENT?

YES

ARE THERE INSURANCE COVERAGES IN FORCE TO COVER THE DAMAGES?

YES

DID YOU SEE A PHYSICIAN SHORTLY AFTER?

YES

DO YOU HAVE INSURANCE TO COVER YOUR DAMAGES?

YES

DO YOU HAVE HEALTH INSURANCE TO COVER YOUR HEALTHCARE?

YES

AS A RESULT OF THE INJURY DID YOU LOSE ANY PROVEABLE AMOUNT OF MONEY DIRECTLY DUE TO LOSS OF INCOME OR OTHER RELATED LOSSES? IF SO, HOW MUCH?

AS A RESULT OF THE ACCIDENT, DID YOU INCUR ANY DIRECT PROVABLE EXPENSE? IF SO, HOW MUCH?

AS A RESULT OF THE ACCIDENT, DO YOU EXPECT TO LOSE A PROVABLE AMOUNT OF INCOME FROM YOUR FUTURE POTENTIAL EARNINGS? IF SO, HOW MUCH?

AS A RESULT OF THE ACCIDENT, WERE THERE ANY OTHER DIRECT PROVABLE LOSSES CAUSED BY THE ACCIDENT? IF SO, HOW MUCH?

WAS THE OTHER PARTY AT FAULT?

YES

NOW

WERE THERE ANY WITNESSES?

YES

WERE PARAMEDICS CALLED?

YES

WAS THE POLICE CALLED?

YES

WAS A POLICE REPORT MADE?

YES

WERE YOU TRANSPORTERD TO A HOSPITAL/GO TO AN URGENT CARE/PHYSICIAN THE SAME DAY?

YES

DOES THE PARTY AT FAULT HAVE INSURANCE TO COVER YOUR DAMAGES?

YES

WERE YOU SO SEVERELY INJURED THAT YOU COULD NOT WALK AFTER THE ACCIDENT?

YES

DID YOU SUFFER LOSS OF CONSCIOUSNESS AFTER THE ACCIDENT?

YES

WOULD YOU ESTIMATE THE DAMAGES WERE MORE THAN $5000?

YES

HOW MANY OF THE FOLLOWING SYMPTOMS DID YOU HAVE AFTER THE ACCIDENT?

PANIC ATTACK

SEVERE ANXIETY

DIFFICULTY SPEAKING

NAUSEA

VOMITING

HEADACHE

DIZZINESS

BLURRED VISION

VISUAL PROBLEMS

NECK PAIN

BACKACHE

CHESTWALL PAIN

CHEST PAIN

SHORTNESS OF BREATH

PARALYSIS

BIFFICULTY WALKING

DIFFICULTY USING HANDS

ABDOMINAL PAIN

NOSEBLEED

BLOOD IN URINE

BLOOD FROM RECTUM OR IN FECES

ANY OTHER BLEEDING

OTHERS

AS A RESULT OF THE ACCIDENT, HOW MANY OF THE FOLLOWING DID YOU SUFFER?

SKIN AND MUSCLE INJURY to HEAD

HEAD TRAUMATIC BRAIN INJURIES WITH BRAIN FUNCTION ISSUES

MEMORY LOSS

MENTAL FUNCTION CHANGES

NECK INJURY

BACK INJURY

BODY INJURY

AMPUTATION

BROKEN BONES/FRACTURES

KNEE MENISCUS INJURIES

HIP INJURY

ROTATOR CUFF INJURY

SPINAL COLUMN INJURY WITH NEUROLOGICAL PROBLEMS

EYE INJURY WITH VISUAL PROBLEMS

FACE INJURIES AND FACIAL DISFIGUREMENT

SKIN AND TISSUE TEARS

BODY DISFIGUREMENTS

NOSE INJURIY

NOSE BREATHING PROBLEMS

SPLEEN INJURY

LIVER INJURY

BOWEL INJURY

BLADDER INJURY

LUNGS INJURY

KIDNEY INJURY

RIB FRACTURE

OTHER ORGAN INJURY

ORTHOPEDIC INJURIES

SPINAL CORD INJURIES

TRAUMATIC BRAIN INJURY (TBI)

BURN INJURY

DISFIGURMENT OF ANY KIND

LOSS OF A PART OF YOUR BODY (DISMEMBERMENT)

EYE INJURY OF ANY KIND

HAND INJURY

FOOT INJURY

HIP INJURY

KNEE INJURY OF ANY KIND

HIP FRACTURE

KNEE FRACTURE

ANKLE FRACTURE

ARM FRACTURE

NECK FRACTURE

SPINAL COLUMN FRACTURE

BONE FRACTURES CUTTING THROUGH THE SKIN

BONE FRACTURES WITH BONE PIECES MOVED APART FROM EACH OTHER BUT NOT THROUGH SKIN

BONE FRCTURES WITH FINE LINE FRACTURES

MULTIPLE BONE FRACTURES

EYE INJURIES WITH VISUAL CHANGES

INJURY LEADING TO INABILITY TO WALK NEEDING WHEELCHAIR PERMANENTLY

INJURY LEADING TO INABILITY TO WALK FOR A FEW WEEKS

INJURY LEADING TO INABILITY TO WORK FOR A FEW WEEKS

INJURY LEADING TO INABILITY TO USE ONE ARM FOR A FEW WEEKS

INJURY LEADING TO INABILITY TO USE BOTH ARMS FOR A FEW WEEKS

INJURY LEADING TO INABILITY TO USE BOTH ARMS PERMANENTLY

INJURY LEADING TO INABILITY TO CARE FOR YOURSELF NEEDING ASSISTANCE

SPINAL CORD INJURY WITH PERMANENT NEUROLOGICAL DEFICIT TO ARMS AND LEGS

HOW DID THE ACCIDENT HAPPEN?

IF A VEHICLE WAS INVOLVED, SKIP THIS QUESTION, AND GO TO THE NEXT QUESTION, OTHERWISE HOW DID THE ACCIDENT HAPPEN?

HOW DID THE ACCIDENT HAPPEN?

WERE YOU THE DRIVER?

YES

WHAT KIND OF VEHICLE?

IF YOUR INJURY WAS CAUSED AS A RESULT OF A MOTORCYCLE, CAR, FAMILY TRUCK, SUV ACCIDENT, PLEASE CONTINUE TO ANSWER THE FOLLOWING QUESTIONS:

MOTORCYCLE

CAR

SUV

SMALL-MEDIUM PASSENGER TRUCK

4X4/LARGE PASSENGER TRUCK

HOW WAS YOUR VEHICLE INVOLVED IN THE ACCIDENT?

OUR VEHICLE HIT THE OTHER VEHICLE

THE OTHER VEHICLE HIT OUR VEHICLE

HOW MUCH DO YOU ESTIMATE THE DAMAGE TO YOUR VEHICLE WAS?

LESS THAN $1500.00

$1500 TO $10,000.00

$10,000.00 TO $20,000.00

$20,000.00 TO $30,000.00

MORE THAN $30,000.00

THE VEHICLE WAS TOTALLED AND NOT DRIVABLE

HOW DID THE ACCIDENT HAPPEN?

THE OTHER VEHICLE BROKE THE LAW AND CAUSED THE ACCIDENT

THE OTHER VEHICLE PASSED THE RED LIGHT AND CAUSED THE ACCIDENT

THE OTHER VEHICLE PULLED IN FRONT OF US INTENTIONALLY

THE OTHER VEHICLE SUDDENLY HIT THE BREAKS TO CAUSE THE ACCIDENT

THE OTHER VEHICLE SIDE SWIPED OUR CAR

THE OTHER VEHICLE HIT OUR CAR FROM THE BACK

THE OTHER VEHICLE HIT OUR CAR FROM THE BACK AND DROVE US INTO THE CAR IN FRONT

OTHER

THE ACCIDENT HAPPENNED IN THEFREEWAY WHILE OUR CAR WAS AT:

FULL STOP

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING AT 65 MILES PER HOUR OR MORE

THE ACCIDENT HAPPENNED IN THE FREEWAY WHILE THE OTHER CAR WAS MOVING:

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING ABOVE 65 MOLE PER HOUR

THE ACCIDENT HAPPENNED IN THE STREET WHILE THE OTHER CAR WAS MOVING:

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING ABOVE 65 MOLE PER HOUR

THE ACCIDENT HAPPENNED IN THE STREET WHILE OUR CAR WAS AT:

FULL STOP

MOVING AT 10 -25 MILES PER HOUR

MOVING AT 25-45 MILES PER HOUR

MOVING AT 45-65 MILES PER HOUR

MOVING AT 65 MILES PER HOUR OR MORE

Thank you!
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