Client Questionnaire

Confidential — Attorney–Client Privileged. This form is for communication with your attorney only. Your answers are saved only on this device until you send them to us. Nothing is transmitted automatically.

When you are done, click Create My Answers at the bottom. That builds a single summary you can copy, download, or email back to Avi. You can also stop partway and your entries will be remembered on this device.

A About You

Basic background the court form asks for.

Where were you born? City and state (and country, if outside the U.S.).

Is this still your current home address?

We have on file: 1640 N. Harvard Blvd., Apt. 2, Los Angeles, CA 90027

Yes, correctNo, it changed

Every place you have lived in the past 5 years. Address and the years you lived there.

We already have: 1640 N. Harvard Blvd., Apt. 2, LA 90027 (June 2022–present) and 1138 N. Edgemont St., Apt. 6, LA 90029 (2018–May 2022). Add anything missing or note “those two are complete.”

Your current employer Name, address, and phone number. If you are not working, write “not currently employed.”

Your jobs over the last 5 years (from before the concert until now). For each: employer name, address, dates worked, your job title, and what you did.

Schools you have attended, starting with high school. For each: school name, address, years attended, highest grade completed, and any degree earned.

B Driver’s License

Did you have a driver’s license on the date of the concert (Nov. 1, 2025)?

YesNo

C The Night of the Concert

A few questions about that evening.

In your own words, please describe what happened that night, as best you remember. Tell it the way you would to a friend. We will put it into the proper legal form for you.

In the 24 hours before the concert, did you drink any alcohol or take any marijuana, drug, or medication of any kind?

NoYes

Who did you go to the concert with, and is there anyone who saw what happened? Names, phone numbers, and emails for anyone who was with you or who witnessed the fall.

Is there anything that could help identify the person who fell on you, or the people who were arguing behind you? Names, what they looked like, anything they said, whether they seemed intoxicated, or anything security or another guest told you.

Did you notice anything about the security, staff, crowd control, or the seating area that seemed unsafe or poorly handled? For example, no staff nearby, an unruly or intoxicated crowd, or anything that worried you before or during the incident.

What cell phone did you have with you that night? The phone number, your carrier (for example Verizon or AT&T), and whose name the account is under.

Did you get any first aid or medical help at the venue that night?

Our file suggests on-site help may have come from Joffe Emergency Services. Please tell us what you remember.

YesNoNot sure

D Your Medical Background

These are routine in every injury case. Please answer as best you can — it is far better that we know now. Anything you are unsure about, we will go over together.

Before this concert, had you ever had pain, an injury, or treatment involving your neck, back, shoulders, or head?

NoYes

Since the concert, have you been in any other accident or re-injured your neck, back, shoulders, or head?

NoYes

Have you treated with any other doctor, therapist, or clinic for these injuries that you may not have mentioned to us yet?

NoYes

Separately from anything above, in the past 10 years have you been in any car accident, fall, or other accident where you needed medical attention?

NoYes

E Medications

We have the prescriptions from the urgent care. We just need your start/stop dates and whether you are still taking anything.

Cyclobenzaprine (muscle relaxer) — when did you start and stop? Are you still taking it?

Naproxen (pain/anti-inflammatory) — when did you start and stop? Still taking it?

Lidocaine patches — when did you start and stop? Still using them?

Are you still taking over-the-counter ibuprofen (Advil) for pain? How often?

Do you have any pharmacy receipts or know what you paid out of pocket for any of these? If you can, attach or photograph the receipts when you send this back.

F Insurance & Out-of-Pocket Costs

What health insurance did you have on the date of the concert? Carrier name and address, the member/policy number, the plan name, and who the policy is under (you or a parent/spouse). A photo of the front and back of your insurance card is perfect.

Has any health insurance, or anyone else, paid or reimbursed any of your medical bills or expenses from this incident?

NoYesNot sure

Are you enrolled in Medicare or Medi-Cal?

If yes, please do not type the number here. We will collect it from you securely. We only need to know whether you are enrolled.

NoYes, MedicareYes, Medi-CalNot sure

Have you paid anything out of your own pocket because of your injuries? For example co-pays, prescriptions, parking or travel to appointments, braces or equipment, or belongings that were damaged. Rough amounts are fine; receipts help.

G Time Off Work & Lost Income

Only if your injuries caused you to miss work or lose income.

Did you miss any work, or lose any income, because of your injuries from this incident?

NoYes

Please tell us:

Do you expect your injuries to cause you to lose income in the future (for example, reduced hours, missed promotions, or career impact)?

NoYesNot sure

H Prior Claims

In the last 10 years, have you filed any other injury claim or lawsuit (other than this one)?

NoYes

In the last 10 years, have you filed a workers’ compensation claim?

NoYes

I Anything Else

Is there anything else you think we should know, or any question above you want to talk through?

Your name and today’s date This confirms you filled out the form. We will send a separate signature page (the official verification) for you to sign before we serve the responses.

Finished? Build your answers and send them back to your attorney.

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