The DePalma Law Firm, LLC

 

For The Defense

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DUI QUESTIONNAIRE


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.

IMPORTANT: Set up your consultation IMMEDIATELY after your release by the police. DO NOT delay engaging a defense attorney simply because you donít 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.



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 donít 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 donít 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.