Client Intake Summary and Questionnaire: Comprehensive Case Foundation Document

Workflow Purpose and Strategic Importance

You are creating the foundational document for a personal injury case—a comprehensive Client Intake Summary that will serve as the authoritative source of truth throughout the entire litigation lifecycle. This document synthesizes information from multiple sources into a single, professionally structured record capturing the client's personal information, accident circumstances, injuries sustained, medical history, insurance coverage, and prior legal matters. Every attorney, paralegal, and case manager working on this matter will rely on the accuracy and completeness of this summary, making precision and thoroughness absolutely essential. The quality of this intake summary directly impacts case strategy development, settlement negotiations, and trial preparation.

Source Material Collection and Verification

Begin by confirming you have received all necessary intake materials before proceeding with document creation. The completed client intake form serves as your primary source, whether submitted as a digital PDF, Word document, or scanned paper form. You will need copies of government-issued identification such as a driver's license or passport to verify the client's identity and personal details with absolute accuracy. Secure all insurance declaration pages showing current coverage, policy numbers, carrier information, and applicable limits. Gather any initial case documents including police reports, accident reports, preliminary medical records, photographs of the incident scene or injuries, and any prior legal correspondence related to this matter or previous claims the client may have filed.

Search through all uploaded documents systematically to locate and extract relevant information, paying particular attention to official forms, signed statements, and verified records. When you encounter scanned or image-based documents, ensure the text is properly recognized and searchable so that critical details are not overlooked. Cross-reference information across multiple sources to identify any discrepancies that require clarification with the client before finalizing the summary.

Personal Information Section: Establishing Client Identity

The Personal Information section establishes the client's legal identity and contact details with precision that will be relied upon throughout the case. Document the client's full legal name exactly as it appears on government-issued identification, noting any aliases, maiden names, or previous names that might appear in medical or insurance records. Record the complete date of birth, Social Security number with appropriate confidentiality markings, current residential address, and mailing address if different from the residence. Capture primary and secondary phone numbers with clear designation of which is preferred for urgent communications, along with the client's email address and any communication preferences or restrictions.

Include emergency contact information with the relationship to the client clearly identified, as this may become relevant if the client's condition deteriorates or urgent decisions are required. Document the client's current occupation and employer details, including job title, employer name and address, and supervisor contact information, as this information becomes critical for lost wage calculations and understanding the physical demands of the client's work. Note the client's marital status and, if married, include the spouse's full name and contact information, as spousal consortium claims may be relevant depending on the severity of injuries sustained.

Accident Details Section: Reconstructing the Incident

The Accident Details section must provide a comprehensive narrative reconstruction of the incident that caused the client's injuries. Begin with the precise date, time, and location of the occurrence, using the most specific address or geographic coordinates available. Document the detailed description of how the accident happened in the client's own words, preserving their narrative voice while organizing the information chronologically and logically. This firsthand account often contains critical details that may not appear in official reports and establishes the client's initial version of events before memories fade or become influenced by subsequent discussions.

Identify all parties involved in the incident, including full names, contact information, insurance carriers, and their role in the accident sequence. For vehicle accidents, record make, model, year, color, license plate numbers, and vehicle identification numbers for all vehicles involved. Document environmental conditions including weather, road surface conditions, lighting, traffic patterns, and any other factors that contributed to or are relevant to understanding how the accident occurred. Note whether police, emergency medical services, or other first responders attended the scene, and record all corresponding report numbers, badge numbers, and agency names.

Capture the names and complete contact information for all witnesses, including bystanders, passengers, and anyone who arrived shortly after the incident. Document whether the client or any other party has given recorded statements to insurance companies, opposing counsel, or investigators, noting the date, recipient, and circumstances of such statements. This information is critical for identifying potential inconsistencies and preparing the client for deposition testimony.

Injuries and Medical Treatment Section: Documenting Harm and Causation

The Injuries and Medical Treatment section establishes the causal link between the accident and the harm suffered by the client. Begin with a detailed catalog of all physical and psychological injuries claimed, using medical terminology where available while also preserving the client's lay descriptions of their symptoms and limitations. Document the initial symptoms experienced at the accident scene, noting whether the client felt immediate pain, loss of consciousness, disorientation, or other acute manifestations of injury. This contemporaneous symptom documentation helps establish causation and rebut defense arguments that injuries developed later from unrelated causes.

Record all emergency medical treatment received immediately following the accident, including ambulance transport, emergency room visits, urgent care consultations, and any immediate diagnostic imaging or testing performed. For each healthcare provider consulted, document the complete name, medical specialty, facility name and address, dates of treatment, diagnoses rendered, and treatments provided. Capture ongoing treatment plans including physical therapy, chiropractic care, pain management, psychological counseling, and any surgical interventions completed or anticipated. List all current medications prescribed as a result of the accident, including dosages and prescribing physicians, along with any medical devices such as braces, crutches, wheelchairs, or assistive equipment the client now requires.

Thoroughly document the impact of injuries on the client's daily activities and quality of life, as this information forms the foundation for pain and suffering damages. Record specific activities the client can no longer perform or can only perform with difficulty, changes in sleep patterns, effects on personal relationships, inability to participate in hobbies or recreational activities, and any emotional or psychological consequences such as anxiety, depression, or post-traumatic stress. Note the client's pain levels using standardized scales, functional limitations in terms of lifting, walking, sitting, or standing tolerances, and any permanent impairment, scarring, or disfigurement that medical providers have identified or that the client reasonably anticipates based on the nature of their injuries.

Insurance Coverage Section: Identifying All Potential Recovery Sources

The Insurance Coverage section requires meticulous documentation of all potentially applicable insurance policies that might provide coverage for the client's injuries or serve as sources of recovery. Begin with the client's own insurance coverage, recording auto insurance policies with carrier names, policy numbers, coverage limits for liability, medical payments, personal injury protection, and uninsured or underinsured motorist coverage. Document the client's health insurance carrier, policy number, group number if applicable, and any coordination of benefits provisions that might affect how medical bills are paid or reimbursed. Include disability insurance policies, both short-term and long-term, along with umbrella or excess liability policies that might provide additional coverage layers.

Document all insurance information obtained for other parties involved in the incident, including at-fault parties and their known coverage limits, as this information directly impacts settlement strategy and case valuation. Note whether the client has already notified any insurance company of the claim, recording the dates of notification, claim numbers assigned, and the names and contact information for adjusters handling the claim. If the accident occurred during the course of employment, document workers' compensation carrier information, claim numbers, and the status of any workers' compensation claim, as this affects both recovery sources and potential subrogation issues.

Search through uploaded insurance documents to extract policy declarations, coverage summaries, and any correspondence from insurance carriers regarding coverage determinations or claim handling. Flag any coverage disputes, reservation of rights letters, or denials that require immediate attorney attention, as these issues may necessitate separate coverage litigation or bad faith claims.

Medical History Section: Distinguishing New Injuries from Pre-Existing Conditions

The Medical History section captures relevant pre-existing conditions and prior medical treatment that defense counsel will inevitably scrutinize when attempting to attribute the client's current symptoms to causes other than the accident. Document all pre-existing conditions affecting the same body parts now injured, prior injuries to the neck, back, extremities, or other areas currently symptomatic, and previous accidents or workers' compensation claims that involved similar mechanisms of injury or affected similar anatomical regions. This proactive documentation allows the legal team to develop strategies for distinguishing acute traumatic injuries from chronic degenerative conditions and for demonstrating aggravation of pre-existing conditions.

Record ongoing medical conditions requiring regular treatment before the accident, such as diabetes, hypertension, arthritis, or psychological conditions, along with all medications the client was taking prior to the incident. Document any prior surgeries or hospitalizations, particularly those involving body parts now affected by accident-related injuries, including the dates, treating physicians, facilities, and outcomes of such prior treatment. Note the client's general health status before the accident, including activity level, exercise habits, and functional abilities, as this baseline information becomes critical when quantifying the impact of accident-related injuries on the client's quality of life.

Prior Legal History Section: Assessing Credibility and Litigation Risk

The Prior Legal History section documents information that may affect the client's credibility, litigation strategy, or potential recovery. Record any previous personal injury claims filed by the client, including the nature of the claim, jurisdiction, outcome, settlement amount or verdict, and whether the client was represented by counsel. Document prior lawsuits whether as plaintiff or defendant, as patterns of litigation may be used by defense counsel to suggest the client is litigious or prone to exaggerating claims. Note any criminal history that might affect credibility if the client testifies at trial, focusing particularly on crimes involving dishonesty or false statements, while being mindful of jurisdictional rules regarding what criminal history is admissible.

Document any bankruptcy filings that could impact recovery, as undisclosed personal injury claims may constitute bankruptcy fraud and disclosed claims may be subject to trustee involvement. Record prior representation by other attorneys, including the names of previous counsel, the matters they handled, and the reasons for termination of those relationships, as this information may reveal potential conflicts of interest or client management issues. Note whether the client has ever been involved in insurance fraud investigations, had claims denied for misrepresentation, or been accused of providing false information in connection with any legal or insurance matter.

Document Structure, Quality Assurance, and Professional Presentation

Generate the final Client Intake Summary as a professionally formatted document using clear hierarchical organization with major sections for Personal Information, Accident Details, Injuries and Medical Treatment, Insurance Coverage, Medical History, and Prior Legal History. Each section should flow logically with appropriate subheadings that guide the reader through the information efficiently. Write in clear, professional language that is accessible to both legal professionals and the client, avoiding unnecessary jargon while maintaining the precision required for legal documentation.

Before finalizing the document, conduct comprehensive quality assurance by verifying that all mandatory fields contain substantive information and flagging any missing critical data for immediate follow-up with the client. Cross-reference extracted data against source documents to ensure accuracy, particularly for policy numbers, dates, monetary amounts, and proper names. Review the document for internal consistency, checking that dates follow logical sequences, that information in different sections does not contradict, and that the narrative flows coherently from incident through current status.

Create the document with proper formatting including consistent heading hierarchy, appropriate fonts and spacing, professional page numbering, and clear section breaks that facilitate navigation. Ensure the document is marked as confidential attorney work product and attorney-client privileged communication, with appropriate headers or footers indicating its protected status. Generate both an editable version for ongoing updates and a final version with embedded navigation features that allow reviewers to quickly locate specific sections.

Workflow Completion and Case Management Integration

Upon completion of quality checks, route the intake summary to the assigned attorney and paralegal for review, highlighting any incomplete sections requiring additional client follow-up or document collection. The summary should include a cover memo identifying specific action items such as missing insurance declarations, incomplete medical records, or factual inconsistencies that require clarification. Do not mark the intake summary as finalized until the supervising attorney has reviewed the document and provided explicit approval, ensuring this foundational case document meets the firm's standards for accuracy and completeness before it becomes the basis for further case development, demand letters, pleadings, and litigation strategy.

Prepare structured data containing key fields for integration with the case management system, ensuring that critical dates such as the accident date and statute of limitations deadline are properly captured in the firm's calendaring system. Link the intake summary to the client's master record and populate relevant database fields for reporting, case tracking, and conflict checking purposes. Store all versions of the intake summary in secure locations with access permissions limited to the assigned case team, maintaining appropriate confidentiality protections for this privileged attorney work product that will guide all subsequent case development and strategic decision-making.