What is the personal injury intake form template?
Assessing a personal injury enquiry means understanding four things quickly: how the accident happened, how badly the person was hurt, what it has cost them, and what evidence exists. This template takes the injured person, or someone helping them, through each in turn.
It works for road traffic accidents, work accidents, slips and trips, medical treatment, faulty products and more. Road accidents ask whether the person was a driver, passenger, cyclist, motorcyclist or pedestrian. The treatment question records when medical help was first sought, and ongoing symptoms, time off work and a 0–10 daily impact scale show how the injury is affecting life now.
Photos and documents can be uploaded on the last page. Each enquiry is saved as a PDF in your FileIt vault, with a consent reminding the enquirer that time limits may apply.
- Best for
- Personal injury law firms, claims managers and legal clinics
- Filled in by
- The injured person or someone helping them
- Time to complete
- About 10 minutes
- Includes
- Accident type, road-user branch, treatment timeline, daily impact scale, lost earnings, witnesses and photo uploads
Who uses a personal injury intake form?
- An online claim enquiry on an injury firm's website
- Parents enquiring about an injury to their child
- Firms following up with enquirers from a phone or advert campaign
- Unions and associations referring injured members to panel firms
- Collecting the story from a work accident while it's fresh
- Legal clinics screening enquiries before a free consultation
Questions on this personal injury intake form
36 questions over 5 pages · includes file upload, conditional questions, multiple pages, consent checkbox, ratings.
1 About you
- Your full name*
- Email*
- Phone*
- Date of birth
- Occupation
- Address
- Who was injured?* Me · My child · Someone else I'm helping
- Injured person's name, age and relationship to you* asked only when it applies
2 The accident
- Date of the accident*
- Approximate time
- Type of accident* Road traffic accident · Accident at work · Slip, trip or fall in a public place · Accident on private property or in a shop · Medical or dental treatment · Faulty product · Assault · Sport or leisure · Other
- Where did it happen?*
- What happened?*
- Were you a… asked only when it applies Driver · Passenger · Cyclist · Motorcyclist · Pedestrian
- Who was it reported to? Police · Employer or accident book · Shop, landlord or site owner · Council or local authority · Not reported yet
- Any reference numbers
3 Injuries & treatment
- What injuries did you suffer?*
- When did you first get medical help?* Emergency department the same day · Doctor or clinic within a week · More than a week later · Not yet
- Hospital, clinic or doctor asked only when it applies
- Are you still having treatment or symptoms?*
- What treatment or symptoms continue? asked only when it applies
- How much are the injuries affecting daily life now?
- Any previous injury or condition affecting the same part of your body?
- What was it, and when? asked only when it applies
4 Losses & insurance
- Have you had time off work or lost income?*
- Roughly how many days? asked only when it applies
- Estimated lost earnings so far asked only when it applies
- Other costs so far
- The other side's insurer or employer, if known
- Have you already made a claim or spoken to another lawyer?*
- Details asked only when it applies
5 Witnesses & evidence
- Were there any witnesses?
- Witness names and contact details asked only when it applies
- Photos of the scene or injuries
- Documents
- Consent*
The personal injury intake form, page by page
1 About you
Name, contact details, date of birth, occupation and address. The enquirer says whether they were injured, or their child or someone else was — in which case the injured person's name, age and relationship are required.
2 The accident
Date, time, type of accident, location and a required step-by-step description. Road traffic accidents ask the person's role on the road. A checklist records who it was reported to, with space for reference numbers.
3 Injuries & treatment
A description of injuries, when medical help was first sought and where, whether treatment or symptoms continue (with details), a 0–10 scale of daily impact, and any previous injury to the same area, with details on a yes.
4 Losses & insurance
Time off work opens days lost and estimated lost earnings. Other costs, the other side's insurer or employer if known, and whether a claim has already been made or another lawyer consulted.
5 Witnesses & evidence
Witness details when there were any, uploads for up to ten photos and ten documents, and a consent confirming accuracy and noting that sending the form doesn't mean the firm has agreed to act.
Make the template yours
- Add accident-type-specific pages, like vehicle details for road accidents
- Change the currency on lost earnings
- Adjust the consent to your jurisdiction and funding arrangements
- Route enquiries into folders by accident type
- Add case handlers as notification emails
- Add a question about how the enquirer heard about the firm
Tips for a better personal injury intake form
- Encourage enquirers to upload photos taken at the scene — they're often the best evidence
- Ask for the accident book reference for work accidents
- Screen for the accident date first; time limits may affect what can be done
- Follow up quickly on enquiries with ongoing treatment, as medical evidence builds over time
Every response becomes a PDF in your vault
The enquiry is filed as a PDF in the vault folder you choose, with photos and documents attached, and you're notified by email. With a respondent copy on, the enquirer gets a PDF too.
Firms typically review liability and injury details, run a conflict check on the other side, and call the enquirer to discuss next steps. The Responses table keeps every enquiry together and exports to CSV.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Personal injury intake form: frequently asked questions
Is this personal injury intake template free?
Yes. It's a starter template in FileIt's Forms app on every plan, including free.
Can someone fill it in for an injured family member?
Yes. Choosing "My child" or "Someone else" asks for the injured person's name, age and relationship.
Does the form say whether someone has a claim?
No. It gathers information for the firm to assess.
Can photos be uploaded from a phone?
Yes. The photo upload takes up to ten images, including HEIC files from iPhones.
Does submitting create a client relationship?
No. The consent says the firm hasn't agreed to act just because the form was sent.
Do enquirers need an account?
No, anyone with the link can fill it in.