Age
Height
Weight (lbs)
Hair Color
Eye Color
Marital Status
Children (#)
Names and Ages
Yes
No
Have you Served in the Military?
Please make a selection.
Branch Of Service
Date of Entry
Date of Discharg
Highest Rank
Medals or Honors
Yes
No
Are you a U.S Citizen?
Please make a selection.
Drivers License Number
Yes
No
Are you a Licensed Pilot?
Please make a selection.
D.L Class
State
Endorsements
Restrictions
Yes
No
Do you ordinarily have difficulty removing it from your purse, billfold, wallet, pocket?
Please make a selection.
Explain
Please enter a message.
Yes
No
At the time of your arrest, did the officer ask to see your driver's license?
Please make a selection.
If so, describe what you did and how much time it took you to show your license.
Please enter a message.
Educational Background (Please list all schools high, college, trade, vocational, etc.)
Please enter a message.
Please list all involvement with charaties or community organizations.
Please enter a message.
Information About the Accident
Arrest information (This Incident)
Arrest Date
Next Court Date
Arresting Officer
Arresting Agency
Charges
Other offense information
If you were charged with any traffic offenses or crimes other than DUI, give the following information on EACH seperate offense:
Offense 1:
Offense 1
Court and court date if different from the DUI
Describe the driving or activities that led to this charge being made against you.
Yes
No
Were you aware that you committed this offense?
Please make a selection.
If 'No' give details to explain:
Please enter a message.
Yes
No
Any witnesses or evidence relating to this offense that supports your claim of innocence?
Please make a selection.
Explain
Please enter a message.
Offense 2:
Offense 2
Court and court date if different from the DUI
Describe the driving or activities that led to this charge being made against you.
Yes
No
Were you aware that you committed this offense?
Please make a selection.
If 'No' give details to explain:
Please enter a message.
Yes
No
Any witnesses or evidence relating to this offense that supports your claim of innocence?
Please make a selection.
Explain
Please enter a message.
Arrest History
Offense 1:
Charge
County
Attorney
Disposition
Offense 2:
Charge
County
Attorney
Disposition
Offense 3:
Charge
County
Attorney
Disposition
Offense 4:
Charge
County
Attorney
Disposition
Offense 5:
Charge
County
Attorney
Disposition
List other prior traffic violations for the past 3 years.
Please enter a message.
Yes
No
Automobile accidents where you were driving in the last 12 months?
Please make a selection.
Provide Context on all accidents
Please enter a message.
Yes
No
Automobile accidents where you were driving in the last 5 years?
Please make a selection.
Provide Context on all accidents
Please enter a message.
Information about vehicle driven at time of arrest
Yes
No
Liability Car Insurance on date of arrest?
Please make a selection.
Insurance Co. (not sales agent)
Policy Number
Policy period at the time of your arrest:
From:
To:
Yes
No
Did you own the vehicle you were driving?
Please make a selection.
If now, Who did?
Yes
No
If you were not the owner of the vehicle, did you have liability insurance on another vehicle on the date of your arrest?
Please make a selection.
Insurance Co. (not sales agent)
Policy Number
Policy period at the time of your arrest:
From:
To:
Yes
No
you did not have insurance at the time of your arrest, have your purchased it since?
Please make a selection.
If yes please provide:
Insurance Co. (not sales agent)
Policy Number
Policy Period from the time of your arrest:
From
To
Vehicle Identification Number
Year
Model
Make
What are your current automobile insurance rates (per year)?
Yes
No
Have you investigated the cost of insurance in the event of a DUI conviction?
Please make a selection.
Medical Information
Often one's medical condition can mimic intoxication and may affect one's performance with the police. Please complete each question fully and completely. An omission can adversely affect the outcome of your case.
If you have sought medical treatment for any physical or psychological condition, please list them below in chronological order from oldest to most recent. Obtain a copy of these medical records for treatment in the past 10 years and provide me with a copy of those records.
Symptom 1:
Date
Symptom
Diagnosis
Lead Physician
Symptom 2:
Date
Symptom
Diagnosis
Lead Physician
Symptom 3:
Date
Symptom
Diagnosis
Lead Physician
Symptom 4:
Date
Symptom
Diagnosis
Lead Physician
Symptom 5:
Date
Symptom
Diagnosis
Lead Physician
Symptom 6:
Date
Symptom
Diagnosis
Lead Physician
Yes
No
Have you been hospitalized at any medical facility?
Please make a selection.
Provide Context on all hospitalizations.
Please enter a message.
When was the last time you were examined by a medical care provider (physician, nurse, practitioner, chiropractor, etc.) other than for a scheduled checkup?
Last Exam Date
What was the purpose of the visit?
What was the diagnosis?
Yes
No
Are you currently under the care of a doctor?
Please make a selection.
For What?
Please enter a message.
Were you taking any medication or drugs at the time such as cold pills, aspirin, antihistamines, tranquilizers, weight control pills, etc.?
List all medications taken within 24 hours of your arrest
(prescription and non-prescription). Include type, dosage, and time you took the medication, particular whether you took aspirin, ibuprofen, Zantec, or Tagamet.
Please enter a message.
What effect does the medication have on you?
Yes
No
Were you warned by your doctor, pharmacists, or nurse, of any side effects of the medication?
Please make a selection.
Yes
No
Do you have any physical disability which would cause imperfect balance, or any injuries that would cause you to look like you were intoxicated?
Please make a selection.
What is your disability?
Yes
No
Do you have a speech impediment or have you attended speech therapy classes?
Please make a selection.
What is your disability?
Yes
No
Was your stomach upset at the time of arrest?
Please make a selection.
Upset stomach, stomach disorder, burping, or belching?
Yes
No
Do you suffer from gastroesophageal reflux disease (GERD)?
Please make a selection.
Yes
No
Do you suffer from non-alcoholic steatohepatitas (NASH), fatty liver, or any other liver condition/disease or liver enzyme abnormality?
Please make a selection.
Yes
No
Do you suffer from any eye diseases or disorders?
Please make a selection.
Yes
No
Were you wearing corrective lenses at the time of your arrest?
Please make a selection.
Please describe in detail what eyewear you use (glasses/contacts).
Yes
No
Do you have Diabetes?
Please make a selection.
Yes
No
Do you have Dyslexia?
Please make a selection.
Yes
No
Do you have an Anxiety disorder?
Please make a selection.
List any other ailments -
Starting with your head and working your way down, list all ailments,
surgeries, medical conditions from which you now suffer or did suffer on the date of your arrest.
Please enter a message.
Yes
No
Do you have or have you been diagnosed with any learning disabilities?
Please make a selection.
Explain
Please enter a message.
Yes
No
Have you been diagnosed with Attention Deficit Disorder (ADD or ADHD)?
Please make a selection.
If so, please list diagnosing physician and date of diagnosis.
Please enter a message.
Yes
No
Have you been prescribed any medication(s) for treatment of ADD or ADHD?
Please make a selection.
If so, please list the medication and dosage, prescribing physician name and phone number
Please enter a message.
Yes
No
Had you taken your ADD/ADHD medication as prescribed on the date of your arrest?
Please make a selection.
Yes
No
Do you have any difficulties with coordination or balance?
Please make a selection.
Explain
Please enter a message.
Yes
No
Do you have any Heart diseases?
Please make a selection.
If so, please explain.
Please enter a message.
How many hours had you worked prior to the arrest?
How much sleep had you had in the 24 hours prior to arrest?
How much sleep do you normally require each night?
Yes
No
Do you suffer from any sleep disorders?
Please make a selection.
If so, list the disorder and the diagnosing physician and date of diagnosis.
Please enter a message.
After having been arrested for an offense such as yours, most people feel "down" or "depressed." That is a natural feeling. If we accept your case, we will do whatever we reasonably can to alleviate your fears, but we are not skilled or trained in the field of psychology. However, it is still important for us to know how you are feeling since your arrest. Please check all the following that apply:
Other Side Effects?
Yes
No
Do you currently smoke?
Please make a selection.
How long have you been a smoker?
Yes
No
If you do not currently smoke, have you been a smoker in the past?
Please make a selection.
How long did you smoke and when did you stop smoking?
Day of Arrest Vehicle and driving conditions
Why were you stopped, if you know?
Explain driving action
Approximately how many miles were on the vehicle at the time of the arrest?
Approximately how long had you driven this vehicle yourself before the date of your arrest? (i.e. six months, two years, etc.)
With what frequency did you drive the vehicle prior to the arrest? (i.e. once per week, etc.)
Please list the extent of use your vehicle is used to perform employment duties
Yes
No
Are you the primary driver in your household?
Please make a selection.
List any defects (mechanical or otherwise) in your car
Weather and Road Conditions (check all that apply):
Approximate Temperature
Were there any other factors that may have affected your driving?
Please enter a message.
The Offense
Date/time/place of arrest (County & Street)
Number of police officers present throughout the arrest, their names, and the color of their uniforms?
Please enter a message.
Yes
No
Do you speak English fluently?
Please make a selection.
Yes
No
Do you believe that your language or accent caused any problems in the officer being able to understand you?
Please make a selection.
What did you first say to the police?
What did the police first say to you?
What conversation did you have with the officer(s) during the ride to the station, and at the jail?
Please enter a message.
Yes
No
At any time did you ask to speak with an attorney?
Please make a selection.
If so, what was the officer's response?
Please enter a message.
Yes
No
Did you tell the officer you had been drinking?
Please make a selection.
If so, what exactly did you say?
Please enter a message.
Yes
No
Were there any passengers in the vehicle?
Please make a selection.
Who? (list names and phone numbers)
Please enter a message.
Yes
No
Were you told you had the right to remain silent, that anything you said could be held against you, that you had the right to an attorney, etc.?
Please make a selection.
At what point in the process?
Please enter a message.
Yes
No
Were you wearing any article of clothing that may have been considered "binding" or restrictive enough to interfere with your ability to perform any of the field sobriety tests?
Please make a selection.
If so, explain
Please enter a message.
Do you recall any law enforcement officer making any inappropriate sexual remark or gesture?
Please make a selection.
If so, explain
Please enter a message.
Route Driven
What route had you taken before arrest (include applicable details of where the stop lights and stop signs were located, how many turns and stops were made, and appropriate distance involved)?
Please enter a message.
Yes
No
Traffic control lights?
Please make a selection.
How Many?
Describe the facts that you believe caused the officer to stop you.
Please enter a message.
Accident
(Complete this section ONLY IF an accident of some type has occured in connection with your DUI arrest.)
Yes
No
Were you involved in an accident?
Please make a selection.
Who called the police or 911?
One car or more than one car?
Describe the accident
Please enter a message.
Yes
No
Were in you inside your vehicle when the officer first arrived on the scene?
Please make a selection.
If NO, give details of where you were in relationship to the vehicles
Please enter a message.
Yes
No
Did the police officer take your driver's license from you?
Please make a selection.
When?
Yes
No
After the accident, did you exit the vehicle or leave the immediate area (for any purpose, such as to call a tow truck, call police, etc.)?
Please make a selection.
If so, give details of how long you were gone, where you went, why you left, etc.
Please enter a message.
Yes
No
Injuries or death to any other person(s)?
Please make a selection.
Yes
No
Do you recall the circumstances leading up to the accident?
Please make a selection.
If so, give details
Please enter a message.
Give details about what questions were asked of you by the police officer(s) and your answers.
Please enter a message.
Yes
No
Did you hit your head, or break the windshield?
Please make a selection.
AdditionalComments
Yes
No
Did the officer ask you if you had anything to drink since the time of the accident?
Please make a selection.
Yes
No
Did you have conversation with the other driver, or with witnesses to the accident?
Please make a selection.
What Was Said?
Roadblocks (Complete this section ONLY if you were arrested at or near a DUI checkpoint)
Yes
No
Was the arrest at a roadblock or license checkpoint?
Please make a selection.
How far ahead did you see it?
How many other cars were ahead of yours?
How long did you wait in line?
Yes
No
Were you given any advance notice of the roadblock (was the roadblock well marked and visible)?
Please make a selection.
If so, give details.
Please enter a message.
Yes
No
Was there a sign advising of a roadblock?
Please make a selection.
Yes
No
Lighted sign?
Please make a selection.
Yes
No
Flares?
Please make a selection.
Yes
No
Orange "traffic control" cones?
Please make a selection.
How many police cars did you see?
Yes
No
Did they have their blue lights on?
Please make a selection.
If so, how many?
Yes
No
Any traffic cones or flares used at "stop" location or place where you were tested?
Please make a selection.
How many police officers did you see?
Describe the exact wording and actions of the officer who approached your window.
Please enter a message.
Yes
No
Did you turn away from the roadbock before reaching it?
Please make a selection.
If so, Explain.
Please enter a message.
Yes
No
Did the officer charge you with an additional traffic violation when you turned to avoid the roadblock?
Please make a selection.
Explain.
Please enter a message.
Evidence Seized
Yes
No
Was your vehicle towed?
Please make a selection.
If so, by whom(Company)?
Yes
No
Was your vehicle return to you?
Please make a selection.
Yes
No
Was your vehicle searched?
Please make a selection.
Yes
No
If so, was anything taken from you and not returned?
Please make a selection.
What was it?
Yes
No
Did you know it was there?
Please make a selection.
DUI Tests Field sobriety tests
Yes
No
Did the officer direct you (or "request" you) to perform any coordiation or roadside sobriety tests?
Please make a selection.
Yes
No
Were you given a choice to refuse them?
Please make a selection.
Exactly when (minutes, seconds after getting out of car) were you first requested to (told to) perform these tests?
Please enter a message.
Statement of Case
Yes
No
Did the officer ask you about your physical limitations or impairments or present illnesses/medications before beginning to "test" you?
Please make a selection.
If so, when, what questions were asked and what were your responses?
Please enter a message.
On
Off
Were your shoes on or off during tests?
Please make a selection.
Describe shoes (if wearing any) during field sobriety tests
Please enter a message.
Describe the lighting in the area
Please enter a message.
On
Off
Did the officer demonstrate the tests for you?
Please make a selection.
Did the officer comment on your performance of any test or tests?
Please make a selection.
What did he say?
Please enter a message.
Yes
No
Did you refuse to take the field sobriety test?
Please make a selection.
If yes, explain why
Please enter a message.
If you were unable to perform any test or did not do well on any test, explain why.
Please enter a message.
Describe the area in which you performed the tests.
Please enter a message.
Yes
No
Did the officer ask you to perform an eye test in which you were asked to follow a pen or a similiar object?
Please make a selection.
Yes
No
Did the officer ask you to stand on one leg?
Please make a selection.
How did you perform on the test?
Please enter a message.
Yes
No
Did the officer ask you to walk a straight line?
Please make a selection.
How did you perform on the test?
Please enter a message.
Yes
No
Did the officer ask you to close your eyes and estimate 30 seconds?
Please make a selection.
How did you perform on the test?
Please enter a message.
Yes
No
Did the officer ask you to touch your nose with the tip of finger?
Please make a selection.
How did you perform on the test?
Please enter a message.
Yes
No
Were you asked to take any other sobriety tests?
Please make a selection.
If so, describe the test(s) and state how you performed.
Please enter a message.
Please describe the following conditions at the scene of the field sobriety tests in as much detail as possible:
Surface where tests were performed
Temperature and winds
Possible distractions (traffic, rotating lights, uneven surface, snow, rain, etc.)
Please enter a message.
Yes
No
Were your passengers permitted to witness the test(s)?
Please make a selection.
Explain
Please enter a message.
Chemical tests in general
Tests Offered by Officer:
Other (Describe)
Tests Given by Officer:
Other (Describe)
Tests Refused
Other (Describe)
Given By:
Time Administered
Number of tests given
Results:
Please enter a message.
Yes
No
Did the officers read any document to you?
Please make a selection.
If so, What?
Yes
No
Did the officers personally hand you a copy?
Please make a selection.
Yes
No
Did you receive a copy of the breath test result?
Please make a selection.
Yes
No
Were you told what would happen if you did not take the test?
Please make a selection.
Breath test (if applicable)
Yes
No
Did the officer remove anything from your mouth?
Please make a selection.
Yes
No
Did you have anything in your mouth?
Please make a selection.
What was it?
Yes
No
Did you smoke before taking the test?
Please make a selection.
How soon before the test?
Yes
No
Did you belch, hiccup, or sneeze 20 minutes prior to blowing?
Please make a selection.
Explain
Prior to the test, for how long would you estimate the officer continuously observerd you?
Please enter a message.
Yes
No
Did the officer have any difficulty operating the machine?
Please make a selection.
Explain
Yes
No
Did you request another test?
Please make a selection.
What type of test did you request?
Who was present when you requested the second test?
Yes
No
Were you allowed to take a second test?
Please make a selection.
Explain
What was the result of the breath test?
Blood test (if applicable)
Where did the officer take you to give you the blood sample?
Yes
No
Was the blood taken from a vein near your elbow?
Please make a selection.
If not where was the blood taken?
If so, from which arm was the blood taken?
How many vials of blood were taken?
Who drew the blood?
What was used to clean the skin before the blood was drawn?
What happened to the vials after the blood was drawn?
After the Arrest Implied consent
Yes
No
Were you told that if you refused the test, your license would be revoked, suspended , or canceled?
Please make a selection.
If so, for how long?
Where and when did the police read your implied consent warning?
Please enter a message.
Yes
No
At the time of the warning, had you been told that you were under arrest?
Please make a selection.
Yes
No
Were you advised that you could contact an attorney before deciding to submit to a test?
Please make a selection.
Yes
No
Were you refused the opportunity to consult with a lawyer before deciding to take the test?
Please make a selection.
If so, please explain.
Please enter a message.
Yes
No
Were you advised that after the officer's test you could take another test by medical personnel of your own choosing?
Please make a selection.
Yes
No
At the time that you refused test(s), had the officer(s) done anything to frighten you or said or done anything to offend you
Please make a selection.
If so, please explain.
Please enter a message.
Yes
No
Were you suffering any pain, discomfort or other physical or mental impairment which would have justified your refusal
Please make a selection.
If so, please explain.
Please enter a message.
Actions after arrest
Yes
No
Were you handcuffed?
Please make a selection.
Front Or Back?
Yes
No
Did that make you angry?
Please make a selection.
Yes
No
Did you ask not to be handcuffed?
Please make a selection.
Yes
No
Did the handcuffs hurt?
Please make a selection.
Yes
No
Were you handcuffed in front of other people?
Please make a selection.
Yes
No
Did you suffer any numbness, pain or discomfort in your hands or arms?
Please make a selection.
Yes
No
Did you complain of pain from handcuffs?
Please make a selection.
Yes
No
Have you sought medical aid about the problem?
Please make a selection.
If so, please explain.
Please enter a message.
Describe everything that took place in route to the police station or the jail: Conversations (who said what, when)
Please enter a message.
Were you transported by the officer who stopped you or by someone else? (provide details)
Please enter a message.
Yes
No
Did you overhear any radio transmissions to or from the officer while he/she was driving you to the testing site/jail/hospital?
Please make a selection.
If yes, what was said?
Please enter a message.
Route taken:
Please enter a message.
Speed of patrol car while transportation (if unusual)
Yes
No
Did you ask the transporting officer any questions during the trip?
Please make a selection.
If yes, what was said?
Please enter a message.
Yes
No
Did you ask to go to a rest room?
Please make a selection.
Yes
No
Did the officer accompany you?
Please make a selection.
What did the officer do or say during this time? (whistle, hum, etc.)
Please enter a message.
Yes
No
Were you cooperative with the officer?
Please make a selection.
If not, describe your behavior:
Please enter a message.
Tests Offered by Officer:
Other (Explain)
If bonding company, list name of agency
When was bond posted?
Yes
No
Is the bonding company paid in full?
Please make a selection.
Conversations with bonding agency personnel (or other person seeking to assist you with bond)? Give details, and with whom.
Please enter a message.
Effects of a possible conviction
How would a conviction affect you personally?
Please enter a message.
How would a conviction affect your family (relationship)?
Please enter a message.
How would a DUI conviction affect your employment?
Please enter a message.
Yes
No
Do you ever have to prove "insurability" in order to drive a "company" car?
Please make a selection.
Yes
No
Do you ever need to rent a rental car, for personal or business use?
Please make a selection.
Yes
No
If so, would denial of access to rental vehicles affect you or your employment?
Please make a selection.
Explain.
Yes
No
Are you involved in any "domestic" (divorce, child custody, etc.) case or judicial dispute that a DUI conviction might affect?
Please make a selection.
Explain.
If you were convicted of DUI, and the conviction appeared on you credit report, how would this affect you personally?
Please enter a message.
Yes
No
Are you professionally licensed (i.e., teacher, attorney) or specially licensed (i.e., pilot, cab driver, etc.) such that you may lose such license as a result of a conviction?
Please make a selection.
If So, Explain.
Yes
No
Does your job involve "security clearance" or "top secret" status such that your employer may be unwilling to accept a DUI conviction?
Please make a selection.
Yes
No
Are you currently enrolled in college or university, where you may be subject to disciplinary suspension for DUI?
Please make a selection.
Yes
No
Do you have a student loan which may be adversely affected by a DUI conviction?
Please make a selection.
Yes
No
Are you presently in military/reserves or planning to join military/reserves?
Please make a selection.
Yes
No
If your license is issued by another state, are you aware that there may be additional penalties and/or insurance assessments if convicted in this state?
Please make a selection.
Yes
No
If you have not done so already, would you like to hire a lawyer in your home state with whom we may confer?
Please make a selection.
Please use the space below and on the back, to give me any other information you may think be important.
Please enter a message.
