Client Questionnaire – 2

Step 1 of 2

Please note that this information is strictly confidential and will not be released to a third party unless so required by law during the course of your case.


Please Complete Our Client Questionnaire. It only takes a minute...

Items marked with * are required

- -
- -
Full Time Part Time
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Please tell us about all credit or services you have been denied in the past 2 years. Changes of terms or changes in credit limits also apply here.

Check off any boxes which reflect a stress related injury that you have suffered from these circumstances. *

Heart Attack
Angina
Chest Pain
Chest Constrictions
Miscarriage
Ulcers
Diabetic Flare-up
Shock
Loss of Appetite
Vomiting
Stomach Ache
Nausea
Weight Loss
Bulimia
Weight Gain
Insomnia
Nightmares
Night Sweats
Becoming Bedridden
Headaches
Muscle Spasms
Dizziness
Fear
Worry
Severe Stress
Hypertension
Concentration Loss
Instability
Hysteria
Fainting
Black-outs
Shortness of Breath
Anxiety
Irritability
Embarrassment
Humiliation
Intimidation
Indignation
Pain/Suffering
Emotional Stress
Loss of Happiness
Nervousness
Crying
Loss of Sleep
Other (complete below)
Not Applicable

Check off any boxes which reflect an out-of-pocket loss that you have suffered from these circumstances. *

Loss of Job
Income
Work Time
Leave From Job
Special Diet
Special Treatment
Impairment of Job Advancement
Job Performance Affected
Medical Expenses
Counseling
Medication
Aspirin
Payment on Invalid Claim/Debt
Transportation Expenses
Conversion of Property
Attorney Fees
Telephone Charges
Faxing
Other (complete below)
Not Applicable

Check off any boxes which reflect a harm that you suffered in your personal relationships. *

Injury to Reputation
Loss of Privacy
Marriage Strain
Relationships Affected
Family
Friend
Loss of Consortium
Impotence
Other (complete below)
Not Applicable