The Law Offices of David S Vogel

Client Questionnaire

Your Full Name:

Your Home Address:

City, State and Zip-Code:

Home Phone Number:

Alternate:

Date Injury Sustained:

Describe Your Injury & Any
Diagnosis Given by a Medical
Provider

Names of Witness to the Event

Describe Your Injuries

Date of First Medical Visit for Care
of Your Injuries:

Pre-existing Medical Condition(s)?

If Yes, Please Describe:
Include similar injuries and
unrelated conditions

If this event was a motor vehicle accident:

Were both parties injured?

Your Insurance Company:

Their Insurance Company:

Were you cited?

Were they cited?

Please describe your driving history:
Including any previous MVAs and/or
citiations you've received. You do not
need to include parking tickets

Have you ever filed a claim for injuries before?

If Yes, Please Describe:
Include the type of claim, approx
date, and outcome

In your own words, describe what happened:


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