DWI Client Questionnaire

Please fill out your responses below

Your Name

Please complete each question fully and completely

1. When was the last time you were examined by a medical care provider (physician, nurse practitioner, chiropractor, etc.) other than for a scheduled checkup?

2. What was the purpose of the visit?

3. What was the diagnosis?

4. Are you currently under the care of a doctor? If so, for what?

5. Please list all medications taken within 36 hours of your arrest (prescription and non-prescription). Include type, dosage and time you took the medication.

6. Were you warned by your doctor or pharmacist of any side effects?

7. Do you have any physical disability which would cause imperfect balance or any injuries that would cause you to look like you were intoxicated when you are not?

8. Any prior sports injuries? Please describe.

9. Any other injuries? Please describe.

10. Have you ever had a concussion? If so, how long ago?

11. Do you exercise regularly?

12. Do you suffer from any eye diseases or disorders?

13. Have you ever been diagnosed with nystagmus?

14. Were you wearing corrective lenses at the time of your arrest?

15. Do you have any difficulties with coordination or balance?

16. Do you have knee problems?

17. Please describe any prior surgeries.

18. Do you have a learning disability?

19. Do you have dyslexia?

20. Have you ever been diagnosed with an anxiety disorder?

21. Have you ever been diagnosed with ADHD? If so, what medication do you take?

22. Have you ever had meningitis?

23. Have you been diagnosed with GERD?

24. Do you suffer from non-alcoholic steatohepatitis (NASH), fatty liver or any other liver condition/ disease or liver enzyme abnormality?

25. Do you suffer from any sleep disorders?

26. If applicable, how many hours had you worked prior to the arrest?

27. How much sleep had you had in the 24 hours prior to arrest?

28. How much sleep do you normally require each night?

29. Do you work around chemicals and solvents?

30. Do you wear a medicinal patch? (ex. Nicotine, motion sickness, birth control)

31. Do you refinish furniture on a regularly basis?

32. Have you had gastric bypass surgery or lap band surgery?

33. Do you suffer from heart disease?

34. Do you have diabetes? If so, which Type? Take insulin?

35. Do you take aspirin daily?

36. At the time of your arrest were you on an unusual or high protein diet? If so, please describe.

37. Are you of Japanese, American Indian or Eskimo descent?

38. Do you suffer from gum disease?

39. Did you vomit before, during or after your arrest?

40. Do you use an inhaler?

41. Do you have dentures, partials, caps, crowns or a retainer?

42. Do you have lung disease such as asthma, chronic bronchitis or emphysema?

43. Do you suffer from stomach ulcers?

44. Do you have Crohn’s disease?

45. Did you take Ambien within 24 hours of your arrest?

46. Do you take Accutane?

47. Is there anything we have not asked about either you or your arrest that you think we should know?

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