Johnson Law Firm | Personal Injury Form

Please take a minute to fill out our personal injury form.

* = required field

Name*:

Address:

City:

State:

Zip Code:

Phone:

Email*:

Date of injury:

Place of injury:

What happened?

What did the other person do wrong?

What parts of your body were injured?

Neck
Upper Back
Middle Back
Lower Back
Headaches

Jaw Pain
Arm Pain
Arm Numbness
Arm Weakness

Ear Popping/Pain
Leg Pain
Leg Numbness
Leg Weakness

What are your injuries from this incident?

For the same parts of your body, do you have any prior injuries?

Yes No

Subsequent injuries?

Yes No

Ambulance:

Emergency Room:

Followup Doctor:

Other Treatment:

Are you still receiving treatment?

Yes No

Whose care are you under now?

Have you ever been convicted of a crime?

Yes No

Have you ever been in a motor vehicle accident?

Yes No

Have you ever had a fall?

Yes No

Have you ever had a lifting injury?

Yes No

Have you ever made an insurance claim?

Yes No

Have you ever had a workers comp claim?

Yes No


	302 West Broad Street Elizabethtown, NC 28337
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