DUI Questionnaire

Today's Date

Basic Information

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Cell Phone

Alternate Phone

Email

May we email you?

Yes

No

Occupation & Employer:

Employer Address

Your Social Security Number:

Birthday

Month

Day

Year

Driver's License Number & State of Issue:

Do you have a Commercial Driver’s License (CDL)?

Yes

No

Have you had driver’s licenses in other states?

Yes

No

If so, list the state and time period in which you were previously licensed

Where were you born?

How were you referred to the Angles Law Firm, LLC?

Individual

Attorney

Internet Site

Other (Please Explain)

What is your preferred method of payment?

DUI/DWI Information

Details win DUI cases. The only way to have a viable chance at being successful in your case is if we know as much detail as possible on the following questions. If you don’t know the answer to a question, leave it blank or indicate so. Please be assured that this questionnaire will be used in our office only, and your confidentiality will be protected.

Have you ever been arrested for a DUI or DWI before?

Yes

No

For each arrest list the approximate date and the outcome of the case (including pending cases, diversions, dismissals, convictions, etc.):

Please list all prior arrests of any kind, including the approximate date of diversion, conviction, or dismissal (also, please list any pending cases)

Were you on diversion or probation at the time of your arrest in this matter?

Yes

No

Where and for what?

Date and time of this DUI Arrest:

Month

Day

Year

Time

HoursMinutes

Court Date and Time:

Month

Day

Year

Time

HoursMinutes

Name of city in which you were arrested:

Exact location of arrest:

Arrested by:

City Police

Sheriff’s Deputy

Highway Patrol

What other citations were issued (speeding, driving while suspended, etc)?

Were you involved in an accident?

Yes

No

Was anyone injured?

Yes

No

What did the officer say he stopped you for?

Did the officer ask you to take field sobriety tests?

Yes

No

Did the officer have you follow a pen or other instrument with your eyes?

Yes

No

Did you...

Pass

Fail

Did the officer have you stand on one leg?

Yes

No

Did you...

Pass

Fail

Did the officer have you walk a line heel-to-toe?

Yes

No

Did you...

Pass

Fail

Did the officer have you say the alphabet?

Yes

No

Did the officer have you count numbers?

Yes

No

Backwards?

Yes

No

Please list any other field tests given:

Did the officer have you blow into a hand-held breath machine?

Yes

No

Were you handcuffed?

Yes

No

Did the officer ever read you your rights (i.e the right to remain silent, anything you say could be used against you, right to an attorney)?

Yes

No

When?

Did the officer ever read you a list of rights about chemical testing to determine your blood or breath alcohol?

Yes

No

Did the officer ever leave you alone during this 15-20 minute period?

Yes

No

Where were you during this time period (in cop car, in a cell, at a desk, etc)?

Did you cough, belch, regurgitate or put anything in your mouth during this 15-20 minute period?

Yes

No

Did you submit to a test of your

Breath

Blood

Urine

Neither

Did you ask the officer if you could take a test other than the test offered?

Yes

No

If you asked for an alternate test, what was the officer’s reply or reaction?

If you refused, did you tell the officer why you refused?

Yes

No

Explain:

Did the officer ever look inside your mouth?

Yes

No

Did you have anything inside your mouth?

Yes

No

Do you have gum disease or problems with bleeding in your mouth?

Yes

No

Were you wearing contacts at the time of arrest?

Yes

No

Have you ever had surgery?

Yes

No

If so, when and for what?

Please list any and all physical illnesses, impairments or disabilities you had at the time of arrest (including trouble with knees, ankles, back, or illness such as a cold, allergies, diabetes, or asthma):

Please list any and all learning disabilities, mental illnesses or disorders you suffered from at the time of your arrest (including Attention Deficit Disorder, manic depression, schizophrenia, etc.):

What and when had you eaten on the date of your arrest?

How long prior to the test had it been since you had an alcoholic drink?

What medications were you taking at the time of arrest?

What specifically do you do at your job?

Do you work around any solvents or chemicals (i.e. paint, paint thinner, gasoline, etc)?

Yes

No

Please list any persons, and their contact information, who were with you at or just prior to the time of your arrest:

Do you suffer from acid reflux, GERD, or other similar problems?

Yes

No

Do you use your car during the course of your employment?

Yes

No

How many miles per month do you drive for work?

How many miles per month do you drive total?

Which defenses, if any, do you think you may have?

List your main concerns going forward:

Please list any other facts that you believe may be important, including what the officer said to you, how he or she treated you, and anything else that could be useful in defending your case or that you think we should know:

I understand no attorney-client relationship is formed by submitting this form. I understand this form is confidential and will be reviewed by the Angles Law Firm, LLC only.