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Client Medical Questionnaire Form

Client Medical Questionnaire

Step 1 of 13

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  • Welcome

    The proper Defense of a DUI charge requires a complete medical history to enable us to completely and properly evaluate your case. Most of the scientific and pseudo-scientific evidence in your case rests on assumptions that you are an "Average Normal Person" and that you are in “Perfect Health .” A complete medical history is also important to help us evaluate your performance on the so-called "Field Sobriety Test" and to help us present alternative explanations for, what may appear to be objective signs of intoxication. Thank you for your time and effort in completing this form—IT WILL HELP US HELP YOU.
  • Date Format: MM slash DD slash YYYY
  • To add another med, click the (+) plus icon.
    Name of MedDosageFrequency 
  • To add another med, click the (+) plus icon.
    Name of MedDosageFrequency 
  • EYES / HGN

  • If YES, please check any box that applies to you:
  • If YES, please check any box that applies to you:
  • On the day of the arrest...

  • If YES, please check any box that applies to you:
  • If YES, please add them here:
  • If YES, please check any box that applies to you:
  • If YES, please explain below:
  • Ears and Hearing

  • If YES, please explain below:
  • Body Temperature

  • Lungs and Respiratory System

  • If YES, please describe below:
  • Endocrine System

  • Enter the medication names below:
  • Gastrointestinal System

  • If YES, please check any box that applies to you:
  • If YES, please check any box that applies to you:
  • Skeletal System

  • If YES, please check any box that applies to you:
  • Please explain here:
  • Muscular System

    At the time of your arrest, were you suffering from any recent or past conditions relating to your muscle, and if so, where?
  • If so, please describe below:
  • If so, please describe below:
  • Circulatory System

  • Neurological/Psychological/Psychiatric

  • Date Format: MM slash DD slash YYYY
  • Enter the name of the medications below:
  • Accident Cases

  • Explain how you were injured:
  • The Mouth

  • If YES, please check any box that applies to you:
  • General Information

  • If YES, what is the condition? Explain below:
  • If YES, what is the condition? Explain below:
  • Almost complete

    Thank you very much for completing this form. This information is very important. We know it took a while to complete, but before you finish, please think about whether we missed anything about your physical condition or health that may be important for us to know. If there is anything you can think of, please list/discuss it below.
  • If so, please tells us about it below:
  • This field is for validation purposes and should be left unchanged.
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About Us

We focus almost exclusively on Ohio OVI – DUI Defense. Founded by nationally known and top-rated Ohio OVI - DUI defense lawyer D. Timothy (Tim) Huey, our firm is dedicated to providing an aggressive but highly professional defense to your Ohio OVI – DUI charges.

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Hours of Operation

Mon-Friday (Weekend by appointment)
9:00am to 5:00pm (24 hours for emergencies)

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Contact Details

614.487.8667

Huey Defense Firm
3240 West Henderson Rd,
Ste B
Columbus Ohio 43220
Telephone: 614-487-8667
Email: staff@hueydefensefirm.com

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