Client Medical Questionnaire Step 1 of 13 7% WelcomeThe 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.Client name*Date Date Format: MM slash DD slash YYYY AgeHeightWeightPlease list any and all medications you take below:To add another med, click the (+) plus icon.Name of MedDosageFrequency List all medications including over-the-counter drugs taken within 24 hours of your arrest.To add another med, click the (+) plus icon.Name of MedDosageFrequency EYES / HGNDoes the following apply to you?If YES, please check any box that applies to you: Do you wear eyeglasses? Were you wearing eyeglasses at the time of arrest? Do you wear contact lenses? Were you wearing contact lenses at the time of arrest? On the day of your arrest, did you do anything which might cause eye strain? What did you do that might cause eye strain?Do you believe you suffer from the following?If YES, please check any box that applies to you: Eye Muscle Fatigue Have you seen a doctor for Eye Muscle Fatigue? Dry Eyes Have you seen a doctor for Dry Eyes? Conjunctivitis Have you seen a doctor for Conjunctivitis? Glaucoma Have you seen a doctor for Glaucoma? “Lazy Eye” or “Cross Eyes” Have you seen a doctor for “Lazy Eye” or “Cross Eyes”? Nystagmus Have you seen a doctor for Nystagmus? On the day of the arrest...On the day of your arrest, had you ingested any the following?If YES, please check any box that applies to you: Caffeine Nicotine Aspirin Antihistamines On the day of your arrest, had you ingested any other over the counter medicines or legal stimulants?If YES, please add them here:On the day of your arrest, did you have or had you suffered from any of the following?If YES, please check any box that applies to you: The flu or a cold Hypertension Hypotension Arteriosclerosis Streptococcus Infection Measles Muscular Dystrophy Multiple Sclerosis Epilepsy Brain Hemorrhage Inner eye injuries Bilateral Amblyopia Unusual sleep patterns Vertigo Dyslexia On the day of your arrest, did you have or had you suffered from any other diagnosed eye problems?If YES, please explain below: Ears and HearingPlease check all that apply to you: Do you wear a hearing aid? Do you have any diagnosed hearing defects? Do you have any diagnosed auditory processing defects? Have you had any inner ear infections? Have you suffered any injury to your ears? Do you get swimmer's ear? Do you have any other diagnosed ear problems?If YES, please explain below: Body TemperatureWhat is your normal body temperature (if you know)?On the day of your arrest, was your body temperature higher than normal?HigherNormalIf it was higher, what was it (if you know)?Please check all that apply to you: Within 24 hours of your arrest, did you have a fever? (Any increased Temperature): Did you have your period or were you pre-menstrual at the time of your arrest? Lungs and Respiratory SystemPlease check all that apply to you: Do you have Asthma? Do you have lung cancer? Do you have Lymphoma? Do you have Hodgkin’s Disease? Do you have throat cancer? Do you have Pulmonary Obstructive Disease? Do you smoke? If YES, how much per day?Do you have any other ailment of the respiratory system?If YES, please describe below: Endocrine SystemPlease check all that apply to you: Are you diabetic? I'm a Type I diabetic I'm a Type II diabetic Do you take insulin? On the day of your arrest were you hypoglycemic? On the day of your arrest were you hyperglycemic? Have you ever had yeast infections? Were you taking antibiotics on the day of your arrest? Are you on oral medication? If YES, what?Enter the medication names below: Gastrointestinal SystemDo you suffer from any of the following?If YES, please check any box that applies to you: Gastric Reflux Disease (acid reflux)? Esophageal Hernia? Heartburn? Did you have to discuss the above conditions with a doctor? Did your doctor recommend any treatment/medication for the above conditions? Do you use Tagament, Zantac or other anti-heartburn medication? What medications/treatments did your doctor recommend?Do you suffer from any of the below?If YES, please check any box that applies to you: Do you suffer from any urinary tract infections? Do you suffer from bladder infections? Skeletal SystemHave you suffered injuries to or have deformities in any of the following areas?If YES, please check any box that applies to you: Feet Ankles Knees Legs Back Spine Hands or Fingers Neck Are you "Pigeon Toed?" Are you "Bow Legged?" Do you suffer from Arthritis? Where do you suffer Arthritis?Please explain here: Muscular SystemAt the time of your arrest, were you suffering from any recent or past conditions relating to your muscle, and if so, where?If Strains, where? Enter below:If Sprains, where? Enter below:If Tears, where? Enter below:If Atrophy, where? Enter below:If Cramps, where? Enter below:Have you suffered any disease of the muscles?If so, please describe below:Do you have Ataxia?YesNoDo you have any condition which you believe effects your balance and coordination?If so, please describe below: Circulatory SystemPlease check all that apply to you: Do you have heart disease? Do you take any blood thinners? Neurological/Psychological/PsychiatricPlease check all that apply to you: Have you ever suffered a stroke? Have you ever suffered any injury to the brain? Have you ever seen a psychologist or psychiatrist? If you checked any of the above, what was the diagnosis?If you were diagnosed, WHEN were you diagnosed? Date Format: MM slash DD slash YYYY Were you placed on medication(s)?YesNoWhich medication(s) were you placed on?Enter the name of the medications below:Please check all that apply to you: Have you been diagnosed with Attention Deficit Disorder? Do you suffer from Depression? Do you experience Anxiety Attacks? Do you get nervous easily? Accident CasesPlease check all that apply to you: Were you wearing seatbelt? Did your airbag deploy? Were you taken to a hospital? Were you put on an IV before having your blood withdrawn? Do you remember talking with a police officer? Did you ever lose consciousness? Did you hit your head? Were you injured in any way? How were you injured?Explain how you were injured:The MouthDo any of the following apply to you?If YES, please check any box that applies to you: Do you have periodontal disease? Do you have dentures? Do you have any extensive Bridgework? Do you have any caps or crowns which are loose? Do you have any condition which introduces blood into your mouth? Were you on antihistamines on the day of your arrest? General InformationDo you have any condition that would affect your ability to perform sobriety tests?If YES, what is the condition? Explain below:Do you have any condition that might make you appear to be intoxicated?If YES, what is the condition? Explain below:Were you pepper sprayed or sprayed with mace?YesNo Almost completeThank 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.Is there anything we missed?If so, please tells us about it below:NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
