DUI Questionnaire

THIS FORM IS COMPLETELY CONFIDENTIAL. Please complete every part it to the best of your ability, and be 100% truthful in every response. The sooner you complete this form, the better your memory will be about the incident and all the important facts surrounding your case. Your detailed answers to these questions will be the primary source of information that we use to evaluate your opportunities for successfully challenging the state's case against you. Not all questions will apply to you. Just write in NA (Not Applicable) if the question doesn’t reflect the facts of your case. There will be some information that you do not have. However, lack of information greatly impedes our ability to discover winning defenses or jury arguments. The questions we ask may seem repetitive, detailed, or unimportant to your case. They are not. We will regularly refer to your answers to assist us in all phases of your case. All answers will be kept confidential. Please take sufficient time to complete this questionnaire. However, don't delay in returning the questionnaire since time can be an important factor in your case. IMPORTANT- Every field is required. If you do not answer, the form will not submit. If you do not receive a "Response Message" after you submit your answers, then your responses have not been submitted. Go back and complete any unanswered questions. The form occasionally skips questions, especially after multiple choice answers. Once you have hit "SUBMIT," come back up to the TOP of the form to make sure that you see the response message. That way, you will know that your answers have been submitted.

1. Client Legal Name * This field is required.
2. Client Preferred Name * This field is required.
3. Address * This field is required.
4. Confidential Email (if you don’t have one, get one)
5. Cell phone # * This field is required.
6. Home phone if different * This field is required.
7. Social Security Number * This field is required.
8. Date of Birth * This field is required.
9. Birthplace * This field is required.
10. Do you have a Commercial Drivers License? * Yes No This field is required.
11. Restrictions on your Drivers License? (If none, say “none”) * This field is required.
12. Was your license valid on your date of arrest? * No Yes This field is required.
13. Expiration date of license? (If you don’t know, say “I don’t know”) * This field is required.
14. All states you have lived in since age 16 * This field is required.
15. How far did you go in school? * This field is required.
16. Who did the vehicle belong to? (If you don’t know, say “I don’t know”) * This field is required.
17. Was the vehicle covered by insurance? If yes, give us the name of your insurance company. * This field is required.
18. What brought you to the attention of the police? (If you don’t know, say “I don’t know”) * This field is required.
19. Was there an accident? (Please give details) * This field is required.
20. What is your U.S. immigration status? (If you are undocumented, even as a 'dreamer,' please email us so that we can consider this in our strategic planning.) * This field is required.
21. Were Miranda warnings given to you? (If you don’t know, say “I don’t know”) * This field is required.
22. Was another vehicle involved? * No Yes This field is required.
23. If another vehicle was involved, please give details. (If you don’t know, say “I don’t know”) * This field is required.
24. Were there any passengers in your vehicle? If so, please give NAME and PHONE. * This field is required.
25.Did you give a statement to the police? (If you don’t know, say “I don’t know”) * I don't know No Yes This field is required.
26. Did anyone else from your car give any statements? * I don’t know No Yes This field is required.
27. Marital status? * This field is required.
28. If anyone gave statements, please summarize what they said. (If you don’t know, say “I don’t know”) * This field is required.
29. Was your vehicle searched? * I don’t know No Yes This field is required.
30. Number of dependents and ages?
31. Name and address of employer. (If none, say “none”)
32. Job Title and Duties (if none, say N/A)
33. Previous alcohol or DUI-related arrests, whether or not resulting in convictions. Please INCLUDE CITY, COUNTY, STATE AND YEAR. If none, say “none.”
NOTE: All of the following questions relate to the PRESENT DUI case, and not to any cases mentioned in question #33. Do you understand? No Yes
34. Did it appear that the police or judge were aware of any prior offense on your record?
35. Were you searched? I don’t remember Yes No
36. INCIDENT-Date and time of arrest
37. Location of arrest (As best you remember)
38. Officer’s name (If you don’t know, say “I don’t know”)
39. What kind of vehicle were you driving?
40. Breath test results? (If you don’t know, say “I don’t know”)
41. Blood test results? If not applicable, say “N/A”
42. Was any property taken from you, your vehicle or any passenger? (If you don’t know, say “I don’t know”)
43. Were you given field sobriety tests? Refused tests Alphabet Finger pat test Finger to nose One leg stand test Walk and turn test Horizontal Gaze Nystagmus (“Pen test”)
44. Urine test results? (If none, say “None”)
45. Did you feel like you were under the influence? No Yes
46. How if at all, did the drinks affect your driving? (If not applicable, say “N/A”)
47. PHYSICAL CONDITION AT ARREST: Height
48. Weight
49. Were you given any other sobriety test not mentioned above? If none, say “none.”
50. How do you feel you performed? If not applicable, say N/A”
51. When did you start drinking and whose company were you in at the time? (If you don’t know, say “I don’t know”)
52. At what locations did you drink? If you didn’t drink, say so.
53. Describe the drinks you had in the order you had them. If none, say “none.”
54. What food did you eat in the 8 hours before you were stopped? If none, say “none.”
55. Of all the people you were with on the day of your arrest, will any testify that you were not under the influence?
56. Had you worked on the day of your arrest? How long? Doing what?
57. Had you been awake for an unusually long time before your arrest? Why?
58. MEDICAL INFO Were you under the care of a physician on the day of your arrest? If so, for what condition(s)?
59. Had you seen a dentist in the 24 hours before your arrest? No Yes
60. Do you have any disability, injury or chronic medical condition which might cause you to limp or might affect your balance?
61. Were you taking any of the following medication on the day of your arrest? None Sleep aids (Ambien? Zolpidem? Lunesta?) Any anti-addiction meds? Weight control pills? Aspirin? Antihistamines (Cold medications?) Tranquilizers (Xanax? Valium?)
62. Please list all medications, both prescription and non-prescription, that you were taking on the date of your arrest.
63. Do you have any of the following? None Speech impediment? Dental bridgework? Dentures?
64. Have you ever been diagnosed with any of the following? None Korchaff’s Syndrome Glaucoma Syphilis Multiple Sclerosis Hypertension (high blood pressure) Epilepsy Hypoglycemia Diabetes
65. On the day of your arrest, were you experiencing any of the following conditions None Extreme chlling Motion sickness Excessive caffeine exposure Vertigo (dizziness) Head trauma Exposure to solvents (paints, auto body putty, dry cleaning fluids) Excessive nicotine exposure
66. Was your stomach upset, or were you burping or gassy? Explain
67. Do you wear None Hearing aid Glasses
68. Was there anything unusual about your appearance at the time of your arrest that may be used to test the officer’s recollection?
69. Were your clothes clean?
70. What type of shoes were you wearing?
71. CONDITION OF CAR Was there anything wrong with any of the following systems? None Windshield Muffler Lights Turn signals Brakes Steering
72. If you checked anything above, please give details. If none, say “none.”
73. Weather conditions Don’t remember Windy Slippery Fog Rain Overcast Sunny Dark Wet Dry
74. Details of weather conditions. (If you don’t know, say “I don’t know”)
75. ROAD CONDITIONS where field tests given None of the above Imaginary line to walk Raining Windy Holes/ruts Rocky Sloping
76. How was traffic? (Light, med, heavy) (If you don’t know, say “I don’t know”)
77. FAMILY Tell us about your family situation. Who you live with. Who you support. Any illnesses or stressful situations within your family? * This field is required.
78. CITIZENSHIP * Undocumented Visa holder Permanent resident (green card) U.S. citizen This field is required.
79. SECURITY STATUS Do you have any government security clearance? * This field is required.
80. Are you on any corporate boards?
81. Are you involved in any family law litigation which could be affected by a conviction
82. Do you possess an FAA Airman’s Certificate (Pilot’s license)?
83. EVENTS ON DAY OF ARREST During the 24 hour period before your arrest, describe your activities IN GREAT DETAIL from the time you woke up until arrest occurred (list them in chronological order) * This field is required.
84. Who did you talk to in the 3 hours before your arrest?
85. Was anyone with you at the time of your arrest? If so, give name, address and phone. (If you don’t know, say “I don’t know”)
86. What were the conditions of the people with you at the time of your arrest? (Sober, drinking, passed out, etc.) If not applicable, say “N/A.”
87. Did anyone including the above people hear any part of the police stop or arrest? If so, please give name, address and phone. If not, say No.
88. Were there any restrictions on your license that you were not complying with at the time of your stop? (If you don’t know, say “I don’t know”)
89. Where was your license when the officer asked for it? (If you don’t know, say “I don’t know”)
90. What were the officer’s first words when they approached? (If you don’t know, say “I don’t know”)
91. How did you respond to the officer’s inquiry? (If you don’t know, say “I don’t know”)
92. Did the officer comment on the following? None You can’t stand up straight You are slurring your words You smell like alcohol Bad driving
93. Were there any containers of alcohol in your car? Did the police find any? Were they opened? Full? Empty? If not applicable, say N/A.”
94. Were there any other suspicious or illegal items in your car? (E.g. weapons, bongs, rolling papers, other drug paraphernalia?)
95. DISTRACTIONS during field sobriety tests None? Rain? Traffic passing nearby? Flashing lights? People gathered?
96. Were you given any verbal tests? Counting (forward or backward) Alphabet Other None
97. Were you trembling when you did any tests?
98. Did the officer make any statement to you that if you passed the tests you would go home?
99. Did you blow into a hand-held alcohol tester?
100. Did the officer let you see the digital readout of any breath test? If so, what was the reading? If not applicable, say “N/A.”
101. Did the officer ever tell you that you would lose your license if you didn’t take the FIELD sobriety tests?
102. Describe how you got along with the various officers you encountered.
103. Did you ever tell police that you wanted a lawyer? If so, when? (If you don’t know, say “I don’t know”)
104. Did you ever tell police that you wanted an independent test of your breath or blood? If so, when? (If you don’t know, say “I don’t know”)
105. When were you first told you were under arrest? (If you don’t know, say “I don’t know”)
106. CAR TOWING: What type of vehicle were you in? Make, Model, Year. (If you don’t know, say “I don’t know”)
107. Was your car towed?
108. If towed, then by whom? (If you don’t know, say “I don’t know”)
109. Were you present when the car was towed from the scene?
110. Where were you when the tow truck arrived? (If you don’t know, say “I don’t know”)
111. Did the tow truck driver observe any of the field sobriety testing? (If you don’t know, say “I don’t know”)
112. Did you get a copy of the tow sheet? (If you don’t know, say “I don’t know”)
113. JAIL-Did you see a clock when you arrived?
114. What time was it when you got to the jail? (If you don’t know, say “I don’t know”)
115. How many officers were involved in processing you?
116. Did you have a conversation with anyone at the jail? If so, who was it?
117. Did the arresting or testing officer make any statements about you or the circumstances of your arrest, or your alcohol reading? (If you don’t know, say “I don’t know”)
118. Did any officer ask you about prior DUI offenses? (If you don’t know, say “I don’t know”)
119. Did you, in response to any officer or on your own, mention any prior DUI offenses? If so, what did you say, and to whom? (If you don’t know, say “I don’t know”)
120. Did the testing officer leave the Intoxilyzer room or your line of sight at any time during the 20 minutes before your breath was tested? (If you don’t know, say “I don’t know”)
121. Did any officer have a walkie-talkie or cell phone within 5 feet during your breath test? (If you don’t know, say “I don’t know”)
122. Were you permitted to use the rest room? (If you don’t know, say “I don’t know”)
123. Were you permitted to make a phone call?
124. Were you given water?
125. Did anyone ask you if you had dentures or a bridge before your breath was tested? (If you don’t know, say “I don’t know”)
126. Did anyone look inside your mouth before your breath was tested? (If you don’t know, say “I don’t know”)
127. Did anyone ask you if you had been around paint vapors, volatile chemicals or solvents during the day prior to when you were stopped? (If you don’t know, say “I don’t know”)
128. Did the officer tell you “keep blowing” while you were giving a sample?
129. Did you have a fever on the day you were arrested?
130. Had you been doing any of the following on the day of your arrest? None Fishing? Boating? Sunbathing? Exercising? Dancing?
131. Do you chew tobacco? If so, did you spit out the chew before your breath test?
132. Do you have any lung problems (asthma, COPD, emphysema) that made the breath test difficult?
133. URINE TEST-IF DONE Were you subjected to a urine test?
134. Where were you when the urine sample was taken? (If you don’t know, say “I don’t know”)
135. Did anyone tell you why they wanted a urine sample? If not applicable, say N/A.
136. Did you tell any police officer at any time about any medications you were taking?
137. RIGHT TO COUNSEL-Did you ever ask for a lawyer? If so, when?
138. Do you need reading glasses? If so, were you able to read any documents they presented to you?
139. ACCIDENT-Were you involved in an accident?
140. Was anyone injured? (If you don’t know, say “I don’t know”)
141. How many cars were involved? (If you don’t know, say “I don’t know”)
142. Describe how the accident took place. (REMEMBER THIS IS ALL CONFIDENTIAL)
143. When officers arrived on the scene, were you in the car or outside?
144. If the EMS was called, were you inside or outside the car when they arrived?
145. After the crash, did you ever leave the immediate area? If so, please give details. (If you don’t know, say “I don’t know”)
146. To your knowledge was anyone else injured?
147. Did the airbag deploy inside YOUR vehicle? If so, how did it affect you?
148. At some point, did the investigating officer tell you that he had finished his CRASH investigation, and was now beginning a DUI investigation? Please give details.
149. Did the officer ever ask you how much you had had to drink? If so, when?
150. Were you ever given Miranda warnings? (“You have a right to remain silent..”) If so, when?
151. DRIVING & CRIMINAL RECORD-Prior to this case, had you EVER been the driver of a vehicle in which another person or a pedestrian was INJURED or KILLED? If so, please give details.
152. Have you ever had a previous criminal conviction of ANY KIND, including DUI, Physical Control, Vehicular Assault or Homicide ANYTIME in you LIFETIME? ANYWHERE?
153. If so, please give details, including State, City, County, Case No. or Citation No. if known. (If you don’t know, say “I don’t know”)
154. If so, did you have a lawyer for that case? Please give details. (If you don’t know, say “I don’t know”)
155. Have you ever been declared a “Habitual Traffic Offender” in any jurisdiction? (If you don’t know, say “I don’t know”)
156. If so, please give details, including the case number and your lawyer’s information. (If you don’t know, say “I don’t know”)
157. Are you now on probation for any offense in any jurisdiction? If so, please give details.
158. Was your license suspended in any jurisdiction at the time of your arrest in this case? If so, please give details.
159. Has your license EVER been suspended for any reason? If so, please give details.
160. Have you ever been charged with any SERIOUS traffic offenses (racing, attempting to elude an officer, hit and run, leaving the scene of an accident)? If so, please give details.
161. Have you ever been charged with any alcohol-related offense, whether or not it involved driving (for example, boating under the influence, drunk and disorderly, open container, underage possession of alcohol) If so, please give details.
162. OTHER ATTORNEYS-Before coming to us, did you consult any other Attorney about your present DUI case? If so, please give details. Remember, this is confidential.
163. Have you hired any other attorney or paid a partial fee relating to this case?
164. Did any previous attorney give you any advice about any plea or a possible challenge to this case? If so, please give details.
165. REFUSAL-If you refused a breath test, what statements or actions were made by the officers just prior to your decision? (If you don’t know, say “I don’t know”)
166. Have you ever had a trusted friend tell you never to take the breath test? (If you don’t know, say “I don’t know”)
167. Have you ever read a news story where a judge, prosecutor or officer refused to take a breath test?
168. Have you provided us with everything you received from the Sheriff, the Jail or the Florida Department of Highway Safety and Motor Vehicles? * This field is required.
169. OTHER CHARGES-Are you aware of any other charges (criminal or traffic) which were filed against you arising out of this incident? If so, please explain. * This field is required.
170. Have you ever entered a rehabilitation facility for drugs or alcohol, or attended an Alcoholics Anonymous meeting? If so, did you have a sponsor? * This field is required.
171. THANK YOU FOR PROMPTLY COMPLETING THIS QUESTIONNAIRE. Is there anything else which you think we should know about the incident which hasn’t been covered above? * This field is required.
172. How did you hear about our office? (Check all that apply) * Other Personal referral (friend or family)? Professional referral (another lawyer)? Other advertising? Yellow Pages? Other internet research? Martindale-Hubbell/Nolo? Avvo.com? Google? This field is required.
173. Can you be more specific about how you found us? * This field is required.

PLEASE NOTE:

If the form does not respond when you hit "SUBMIT," check to make sure that you have not left any questions blank.

Once you have hit "SUBMIT," please scroll to the top of this page to make sure that you see a Response Message. That way, you will know that your answers have been submitted. Thank you.

PLEASE NOTE:

If the form does not respond when you hit "SUBMIT," check to make sure that you have not left any questions blank.

Once you have hit "SUBMIT," please scroll to the top of this page to make sure that you see a Response Message. That way, you will know that your answers have been submitted. Thank you.

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