GOOBERMAN S MEDICAL/LEGAL QUESTIONNAIRE
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- Percival May
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1 Date: GOOBERMAN S MEDICAL/LEGAL QUESTIONNAIRE Name: Age: Wt. Ht. DOB: Address: Phone Numbers: Home:_ Lawyer: Town of Arrest: Work: Telephone Number: Fax Number: Date & Time of Arrest: at Is English your first language? Yes No If not, what is your primary language? Was this a DWI or refusal Alcohol or drugs Was there a breath test? Yes No What were the results of the breath test? Where was the breath test conducted? Roadside Police Department Both Was a blood test or urinalysis performed? Blood test Urinalysis Where were the toxicology tests performed? Hospital Police Laboratory What were the substances and levels of those tests? Was there a motor vehicle accident? Yes No Was there airbag deployment? Yes No Did you lose consciousness? Yes No Did you suffer a head injury? Yes No Were SFST s performed? Yes No Were any of the following of consequence in the performance: Flashing lights Yes No Headlights Yes No Uneven ground Yes No Debris Yes No Wet Surface Yes No Icy Surface Yes No What time do you usually awake in the morning? What time did you wake up that morning? _ Were you bleeding at the time of the arrest? Yes No If so, where were you bleeding from? Where/Location Cuts (lacerations) Scratches (abrasions) Broken bones (fractures) Bruises (hematomas)
2 What medications were you taking at the time of the arrest? Reason? Are you a diabetic Yes No Medications Were you suffering from any injuries at the time of the arrest? If so, where? Explanation of Injuries Ankles Feet Legs Back Knee Hips Were you receiving any treatment for any of the following neurological conditions at the time of the arrest? Please Explain Vertigo (Dizzy) Seizure disorder Head injury Nerve damage Learning disability Stroke Depression Sleep Apnea Do you see a medical doctor regularly? Yes No Do you see a podiatrist? Yes No Do you have respiratory allergies? Yes No Do you see a chiropractor regularly? Yes No Do you see a psychiatrist/therapist? Yes No Do you suffer from sinusitis? Yes No Did you have a cold, flu or bronchitis at the time of the arrest? Yes No Have you been hospitalized in the past? Yes No If so, was surgery performed? Yes No What surgeries?: _ Did you ever have bariatric surgery performed? Yes No Do you suffer from ongoing problems with any of the following symptoms? Post nasal drip Hoarseness Nasal congestion Something caught in your throat Halitosis (bad breath) Rhinitis (runny nose) Sore throat Choking spells Excess salivation Voice changes Persistent cough Ear pain (otalgia) Throat clearing Neck pain not related to trauma 2
3 Have you ever had sinus x rays? Yes No a copy to your attorney. If so, please obtain the report (if not already produced) and provide Have you ever been diagnosed with any of the following: Asthma Emphysema COPD Yes No Yes No Yes No Do you use an inhaler? Yes No Pulmonary Nasal Do you have any of the following: Hiatal hernia Problems with heartburn, belching or burping Difficulty swallowing Hoarseness in the morning Sore throat in the morning Please check Do you use antacids or other stomach medications regularly? Yes No Over the counter medications Yes No Prescribed by a doctor Yes No Do you have high blood pressure? Yes No What medications do you take? Have you ever had an upper GI x ray? Yes No If so, please obtain a report and provide a copy to your attorney. Do you have: Dental plates or bridges Gum Disease (gingivitis, pyorrhea) Dentures If so, do you use adhesives? Yes No If yes, what brand? Did you use a mouth wash or breath spray at the time of the arrest? Yes No Did you eat anything peppermint around the time of the arrest? Yes No If so, what? Did you have anything in your mouth at the time of the breath test? Yes No Dental apparatus Gum Jewelry Tobacco Other substance, specifically Did you have any portable electronic devices on your person at the time of the breath test? Yes No Hearing aids Pacemaker Defibrillator Medication pump Glucose monitor Cell phone Radio 3
4 Did you notice any electronic devices in the room when the breathylyzer was performed? Yes No If so, what? 4
5 IDEAL BODY WEIGHTS (IBW) WOMEN, AGES (All weights include 3 pounds of clothing) (All heights include 1 inch for shoes) HEIGHT Feet Inches SMALL MEDIUM LARGE MEN, AGES (All weights include 5 pounds of clothing) (All heights include 1 inch for shoes) HEIGHT Feet Inches SMALL MEDIUM LARGE
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