DUI QUESTIONNAIRE
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This questionnaire is for the use of our prospective DUI or drink driving clients. Print this questionnaire and use it to make notes of what happened while your memory of the incident is fresh. Then bring the completed questionnaire AND all the papers given to you by the police or the court with you to The DePalma Law Firm for your free initial consultation. You can save time at the consultation if you fax this questionnaire and your papers to our office ahead of time at (719) 687-2334.
Click here to go back to the DUI Page.
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IMPORTANT: Set up your consultation IMMEDIATELY after your release by the police. DO NOT delay engaging a defense attorney simply because you don’t have the time to fill out the questionnaire. Come in for your consultation and we will fill out the questionnaire together.
WARNING: This questionnaire is confidential and should not be given to the police, the District Attorney or any other representative of the government. This document may not be protected by the attorney client privilege and may be used against you in a court of law until you engage the services of a defense attorney.
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1) CLIENT INFORMATION
Name ______________________________
Address
______________________________
______________________________
______________________________
Home Phone (_____) _______________________
Cell Phone (_____) _______________________
Work Phone (_____) _______________________
Fax (_____) _______________________
Email ______________________________
Age ____ Years.
Gender M / F
Height ____ Feet, _____ Inches.
Weight ____ Lbs.
Do you possess a Commercial Driver's License (CDL)? Yes / No
2) MEDICAL HISTORY
What is your general health? ___________________________________________________________________________
List all of your medical problems at the time of the stop: ___________________________________________________________________________
Do you have any physical conditions which affect walking, balance or coordination? Yes / No
If so, please describe: ____________________________________________________________________________
____________________________________________________________________________
Are you a diabetic? Yes / No
If so, please describe: ____________________________________________________________________________
Do you have any speech problems? Yes / No
If so, please describe: ____________________________________________________________________________
Is your eye sight impaired in any way? Yes / No
If so, please describe: ____________________________________________________________________________
Were you taking any medication, drug or dietary supplement at the time of the stop? Yes / No
If so, please list all medications, drugs or supplements: ____________________________________________________________________________
____________________________________________________________________________
Have you been working two jobs, overtime or under special conditions which cause you eye fatigue or strain? Yes / No
If so, please describe: ____________________________________________________________________________
Does your employment expose you to chemicals, solvents, gases, volatile liquids and the like? Yes / No
If so, please describe: ____________________________________________________________________________
Are you a smoker? Yes / No
If so, for how many years": _________
How many packs do you smoke per day?
_________
3) ACTIVITIES BEFORE THE STOP
Did you eat any food during the 12 hours prior to when the police stopped you? Yes / No
If so, describe what you ate and when you ate it:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Did you drink any alcoholic beverages during the 12 hours prior to when the
police stopped you? Yes / No
If so, describe what you drank and when you drank it:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
What time did you stop drinking alcoholic beverages before the police
stopped you? (If you don’t know the time, about how many minutes before
you were stopped?)
__________________________________________________________________________
Did you take any medications, drugs or dietary supplements during the 12 hours prior to when the police stopped you? Yes / No
If so, describe what you took and when you took it:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Did you undergo any physically or mentally strenuous event before you started driving?
Yes / No
If so, please describe: ____________________________________________________________________________
How much sleep did you have in the 24 hours prior to the stop? ___________
4) DRIVING BEFORE THE STOP
Please describe where you drove between the time you stopped drinking
alcoholic beverages or taking a drug and when the police stopped you.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Where were you driving to?
__________________________________________________________________________
What was the weather like while you were driving?
__________________________________________________________________________
Was there any road construction on the route you were driving? Yes / No.
If so, please describe the road construction and its location(s)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
When did you first observe the police who stopped you?
__________________________________________________________________________
Were you driving or stopped when the police contacted you? Yes / No
If you were driving, please describe your driving after the police first
observed you.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
5) ACCIDENT
Were you involved in an accident? Yes / No.
If yes, please describe the accident.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6) STOPPED VEHICLE
If your vehicle was stopped when the police first contacted you and the
police did not stop you, then please answer the following questions:
Were you awake or asleep when the police first contacted you? _____________
Where were you located in the vehicle when the police first contacted you?
__________________________________________________________________________
Where were your car keys located when the police first contacted you? (in
the ignition, in your clothing or elsewhere in the car).
__________________________________________________________________________
Was the car engine running when the police first contacted you? Yes / No.
Were the car headlights on when the police first contacted you? Yes / No.
Was the car radio on when the police first contacted you? Yes / No.
Was the car AC or heat on when the police first contacted you? Yes / No.
7) POLICE STOP
Did the police officer tell you why he stopped you? Yes / No.
If so, what did the officer tell you about why he stopped you?
__________________________________________________________________________
__________________________________________________________________________
Did the police officer ask you to step out of your car? Yes / No.
Did you step out of the car when the police officer asked you? Yes / No.
What did the police officer say to you BEFORE you stepped out of the car?
__________________________________________________________________________
__________________________________________________________________________
What did you say to the police officer BEFORE you stepped out of the car?
__________________________________________________________________________
__________________________________________________________________________
What did the police officer say to you AFTER you stepped out of the car?
__________________________________________________________________________
__________________________________________________________________________
What did you say to the police officer AFTER you stepped out of the car?
__________________________________________________________________________
__________________________________________________________________________
7) FIELD SOBRIETY EXERCISES
Were you asked to perform any physical tests or field sobriety exercises?
Yes / No
Did the officer inform you that the field sobriety exercises were voluntary? Yes / No
Did you perform the requested physical tests or field sobriety exercises?
Yes / No
What type of shoes were you wearing? ____________________________________________________________________________
What type of clothing were you wearing? ____________________________________________________________________________
What field sobriety exercises did you perform? (Check all that apply).
___ Follow a pen, finger or other object with your eyes without moving
head.
___ Standing with your feet together, head tilted back and eyes closed.
___ Touching your nose with your finger.
___ Standing with one foot on the ground and the other foot raised.
___ Walking heel to toe along a line.
___ Patting your hands together.
___ Counting on your fingers.
___ Saying or writing the ABCs
___ Other (Describe):
__________________________________________________________________________
Did the police officer tell you anything about how you performed in the field sobriety exercises? Yes / No.
If so, what did the police officer tell you about how you performed in the field sobriety exercises?
__________________________________________________________________________
__________________________________________________________________________
8) BLOOD ALCOHOL TESTS
Were you asked to blow into a machine to measure your blood alcohol?
Yes / No
If so, please describe: ____________________________________________________________________________
____________________________________________________________________________
Did the police read an implied consent warning to you before you took the test which described the penalties for refusing to take the test? Yes / No.
Did you agree to provide the requested breath test? Yes / No
Did a police officer watch you for 20 minutes or more between asking you to perform a breath test and actually having you blow into the breath test machine? Yes / No.
Did the police ask you if you had anything in your mouth before you blew into the machine? Yes / No.
Did the police check to see if you had anything in your mouth before you blew into the machine? Yes / No.
Did you burp, belch or vomit anything into your mouth before blowing into the machine? Yes / No.
Did you see anyone blow into the machine just before you blew into the machine? Yes / No.
What were the numerical results of your breath test, if you know?
__________________________________________________________________________
Was your blood drawn to measure your blood alcohol? Yes / No
Did the police read an implied consent warning to you before you took the
test, which described the penalties for refusing to take the test? Yes / No.
What were the numerical results of your blood test, if you know?
__________________________________________________________________________
Were you asked to provide a urine sample? Yes / No
9) ARREST
Arrest Date __________________
Arrest Time ______am / pm
Place of Arrest __________________________________________________________
What agency arrested you? ______________________________________________
What citations were you given by the law enforcement officer?
__________________________________________________________________________
10) WITNESSES
Were there any witnesses to your driving before the police stop? Yes / No.
Were there any witnesses to the accident? Yes / No.
Were there any witnesses when the police were with you? Yes / No.
If so, please note what you know of the names, addresses, and telephone
numbers of the witnesses. If you don’t know who the witnesses were,
please describe what the witnesses looked like.
__________________________________________________________________________
__________________________________________________________________________
11) PRIOR DUI CONVICTIONS
Have you ever been arrested before for driving under the influence of
alcohol or drugs? Yes / No
If so, describe where and when you were previously arrested.
__________________________________________________________________________
Have you ever been convicted before for driving under the influence of
alcohol or drugs? Yes / No.
If so, describe where and when you were previously convicted:
__________________________________________________________________________
12) FUTURE COURT DATE
When and where is your next court hearing scheduled in this matter?
__________________________________________________________________________
IF YOU INTEND TO ENGAGE AN ATTORNEY, YOU SHOULD DO SO BEFORE THIS COURT DATE.
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