DUI Questionnaire
(* indicates a required field)
A.  Personal Information
First Name
 *
Last Name
 *
Social Security Number
Address 1
Address 2
City
 *
State
 *
Zip
 *
Phone # OK to call you @ this #?   yes no *
Alternate Phone# OK to call you @ this #?   yes no
Fax # OK to fax you @ this #?   yes no
e-mail address OK to e-mail you here?   yes no
Race:
Black   Hispanic   Caucasian   Other
(Note: This question is asked for purposes of legal strategy and is not intended for any discriminatory purposes)
Height
Weight
Age
Date of birth
Place of birth
US Citizen
 yes   no
Military
 yes   no If yes, what branch? 
Education
Occupation
Employer
Employer's address
Employer phone number
Marital Status Married Single Separated Divorced
Widowed
Children  
yes no
If yes, what are his/her/their names and ages?
Driver's license?
yes   no
Valid at time of arrest?
yes no
Driver's license number:
Required for work?   yes   no
Commercial license?   yes   no
B.  Prior Arrests and / or Convictions
Is this your first DUI in your lifetime anywhere, anytime?
 yes   no
If you have had prior DUls please list them below:

Month:   Year:     Court: 
Result:   Guilty   Not Guilty   Nolo
Month:   Year:     Court: 
Result:   Guilty   Not Guilty   Nolo
Month:   Year:     Court: 
Result:   Guilty   Not Guilty   Nolo
Are you currently on probation or parole?
yes   no
 If yes, what court?
What offense?
C. History of Current Charge
Date of Arrest
 *
Time of Arrest
 am PM
Day of the week
State where Arrested
City where Arrested
 *
County where Arrested
 *
Court Date (leave blank if unsure)
 *
Time of Court
Name of Court
 *
Other Tickets/Charges received with this DUI (check all that apply):
Weaving/unsafe lane change
Speeding
Driving on suspended license
License not in possession
Open container
Illegal U-turn
Running Red Light
Defective Equipment
No Proof of Insurance
Failure to Yield
Other (Please Specify below...)

Please specify other charges not listed above
Why were you stopped/arrested, according to officer?
Was there an accident?
yes   no    not sure

Was anyone injured? (check all that apply):
No one was hurt/Not applicable
Myself
Passenger(s) in my vehicle
Passenger(s) in another vehicle
Pedestrian
Not sure
Were you stopped at a roadblock?
 yes   no
Were you given field sobriety tests at the location where you were stopped?
yes   no   Don't recall   Refused
Which field sobriety tests were you given?
Handheld Breath Test
Walk-and-turn 9 steps heel to toe
One-Leg Stand
Follow-the-Pen-With-Eyes
Say the Alphabet
Touch Your Nose
Other (Please Specify below...)

Please specify other tests you took, that are not listed above:
Did officer advise you that tests were optional and that no penalty would result from not doing them?
yes   no
Did you take a breath test?
 yes No, I refused None offered Not sure
Did you take a blood test?
 yes No, I refused None offered Not sure
Any other test? yes No
If yes, what kind of test (please name or describe)?
Name of testing Officer
Breath/Blood test results
Check here if test results are pending 
If you took a breath test, at any time did you ever ask for or inquire about getting your own independent blood, breath or urine test?
 yes   no
Did you get an independent blood or urine test?
yes   no
If yes, what was the result?
Check here if test results are pending
Name of arresting Officer
Name of police department
 *
Street or location where stopped
County where stopped
 *
Did you ever ask to call an attorney?
yes   no
If yes, when (give details)?
Were you advised of your Miranda rights?
 yes   no
Was your car towed?
 yes   no
Was bond posted for your release?
 yes   no Amount posted: $
Was the bond posted by a bail bondsman?
 yes   no
Were there any witnesses with you who could testify for you?
 yes   no

Was there anyone with you who observed your behavior for at least 4 hours
prior to being stopped?
yes   no
If yes, please list his/her/their name(s), address(es), and telephone number(s):

Name
Address
Telephone Number
Name
  Address
 Telephone Number
Name
Address
Telephone Number

Did you consider yourself to be under the influence of an alcoholic beverage at the time of your arrest?
 yes   no
Do you believe the drinks you had prior to your arrest affected your driving?
 yes   no

Additional comments
D. Physical Condition at Time of Arrest
Did you eat prior to your arrest?
 yes   no
If yes, what time?
am PM
What did you eat?
At what time did you start drinking prior to your arrest?
 am pm
What did you drink?
*
 How much? *
How were you dressed at the time of your arrest?
 Describe:
Was there anything unusual about your appearance?
 yes   no Describe:
Were your clothes soiled or clean?
 Soiled   Clean
What type of footwear were you wearing?
E. Medical
Were you under a doctor's care at the time of your arrest?
 yes   no
Had you seen a dentist within the 24-hour period prior to your arrest?
 yes   no
Do you have a physical disability which would cause you to limp or have imperfect balance, or did you have any injuries at the time of the arrest that would cause you to look intoxicated?
 yes   no
Were you taking any medication or drugs around the time of your arrest such as cold pills, antihistamines, tranquilizers, weight control pills, aspirin, etc.?
 yes   no Describe:
Do you have a speech impairment?
 yes   no
Do you have any dental work which could have absorbed alcohol?
 yes   no
Do you have:
False teeth? yes   no
Heart disease?
 yes  no
Diabetes? yes   no
Do you have any other medical problems that would have influenced your physical condition at the time of your arrest?
yes   no
If yes, please describe:
Was your stomach upset around the time of your arrest?
 yes   no
Did you or do you wear glasses and/or contact lenses?
 yes   no
If yes, what is your corrective reading?
How many hours had you worked prior to your arrest?
F. Condition of car
Last date of repair or examination of vehicle by mechanic:
Were there any mechanical defects in your car?
 yes   no Describe

G. Weather and Road Conditions
Please check all that apply
Blacktop Dirt road Dark Daybreak
Twilight Foggy Rainy Sleet
Hail Snow Drizzle Slippery
Normal Wet Dry Other
H. For our information, How did you find us?
Friend Attorney Coworker
Other individual Yellow pages Brochure
Newsletter Television Radio
MaceLaw website drunkdriving.com Other
If referred by a person, what is his/her name?