Phone: 215-860-5800
403 Executive Drive
Langhorne, PA 19047

DUI Arrest or Traffic Tickets? Get Help Now!

D.U.I. Questionnaire

Personal Data

First Name:

Last Name:

Telephone:

Email:

Date of Birth:

Age:

Height:

Weight:

Address:

Town:

Zip:

Glasses or Contacts:

Prior D.U.I. Arrests

Date of DUI:

Location of DUI:

Result:

Condition of Motor Vehicle

Make:

Model:

Year:

Number of Miles:

Condition of Vehicle:

Any Recalls:

Reason For Recall:

Date Last Inspected:

Mechanical Issues?

Describe Alignment:

Medical Condition

An officer may testify in court that you did poorly on field sobriety tests prior to your arrest. It is important to ascertain if any medical or physical reasons caused this poor performance. List all physical or medical reasons that may have caused or contributed to substandard performance.

Prior Foot Injuries: Yes No

Prior Knee Problems: Yes No

Diabetic: Yes No

Inner Ear Problems: Yes No

Prior Back Problems: Yes No

Difficulty Seeing at Night: Yes No

Pulmonary Disease: Yes No

Any Speech Problems: Yes No

Recently to Dentist: Yes No

Age: Yes No

Weight: Yes No

False Teeth: Yes No

Recent Injury: Yes No

Weather and Road Conditions

Weather and road conditions play an important part in how many motorists drive. Frequently, rain, snow, sleet, glare on the highway, potholes, obstructions, distractions, etc., cause a motorist to weave, cross a center line, travel onto the berm of a highway or even cause and accident. Please check all appropriate boxes.

Raining: Yes No

Sleeting: Yes No

Snow on Roads: Yes No

Potholes: Yes No

Glare on Highway: Yes No

Very Windy: Yes No

No Reflectors on Road: Yes No

Lines Clearly Marked: Yes No

Snowing: Yes No

Icy Roads: Yes No

Gravels, Stones, Rocks: Yes No

Line Worn Off Road: Yes No

Approx. Temperature:

Obstructions (List):

Distractions (List):

Reason for Stop

An officer must state in court why he stopped you unless an accident was involved. It is thus important to ascertain if a valid basis existed for the stop of your car.

Told Reason Why Stopped: Yes No

Were you asked if you knew the reason why you were stopped? Yes No

Weaving: Yes No

Were you asked why weaving occurred? Yes No

Crossing Center Line: Yes No

Tailgating: Yes No

Red Light Violation: Yes No

Wrong Way on Street: Yes No

Travelling Too Slow: Yes No

Going Off Road: Yes No

Stop Sign Violation: Yes No

Wrong Lane: Yes No

Speeding: Yes No

Wide Turn: Yes No

Swerving: Yes No

Headlights Off: Yes No

Non-moving Violation: Yes No

Straddling Center: Yes No

Other:

Reasons For Possible Violation

Too Many Drinks: Yes No

Mechanical Problems: Yes No

Adjusting Radio/Tape/CD: Yes No

Illness: Yes No

Debris on Road: Yes No

Using Handkerchief: Yes No

Dropped Cigarrette: Yes No

Weather Conditions: Yes No

Medical Conditions: Yes No

Night Blindness: Yes No

Lighting Cigarette: Yes No

Talking on Phone: Yes No

Sneezing: Yes No

Eating/Drinking: Yes No

Adjusting Seat Belt: Yes No

Contact Lens Problem: Yes No

High Beams in Eyes: Yes No

Road Conditions: Yes No

Other Reasons For Possible Violation:

Other Normal or Abnormal Driving By Motorist

Adjusted High Beams: Yes No

Failed to Use Turn Signal: Yes No

Failed to Use Flashers: Yes No

Stopped at Safe Location: Yes No

Stopped on Roadway: Yes No

Pulled Off Road: Yes No

Parked Over 6' Curb: Yes No

Stopped Unlawful Spot: Yes No

Parked Parallel: Yes No

Brake/Gears Used: Yes No

Police Chased: Yes No

Stopped Reasonable Time: Yes No

Parked at an Angle: Yes No

Distance to Stop:

Odor of Alcohol

Usually a police officer will testify that the motorist had an odor of alcohol on his breath. However, the mere fact that a motorist has an odor on his breath does not mean that he or she is incapable of safedriving. Check all appropriate boxes.

Beer Spilled on You: Yes No

Recent Drinking: Yes No

Non-alcoholic Beer: Yes No

Diabetic: Yes No

Concussion: Yes No

Other: Yes No

Fumbling of Cards

Sometimes a police officer will testify that the motorist had difficulty producing his or her license and vehicle registration. Please check all applicable boxes.

Fumbled With Cards: Yes No

Passed Over License: Yes No

Several Registrations: Yes No

Cards Out Before Asked: Yes No

Flashlight in Eyes: Yes No

Nervousness: Yes No

Sure Handling Cards: Yes No

Dropped Cards: Yes No

Thick Wallet: Yes No

No Difficulty: Yes No

Cards in Glove Box: Yes No

Interior Dark: Yes No

Interior Lit: Yes No

The Motorist's Eyes

Often a police officer will testify that the motorist's eyes appeared to be glassy and bloodshot. Kindly check all appropriate boxes.

Hard/Soft Contacts: Yes No

Wearing Glasses at Time: Yes No

Awake Many Hours: Yes No

Eye Problems: Yes No

Artificial Eye: Yes No

Always Bloodshot: Yes No

Condition Unknown: Yes No

Tedious Eye Work: Yes No

List: Computers, etc.:

The Motorist's Speech

In most DUI cases the police officer will testify that he or she felt that the motorist's speech was slurred or mumbled even though he or she never spoke to the person before. Please check all applicable boxes.

Slurred Speech: Yes No

Told Speech Was Bad: Yes No

False Teeth: Yes No

Nervousness: Yes No

Unknown: Yes No

Answered All Questions: Yes No

Normal Speech: Yes No

Asked if there was speech: Yes No

Problem: Yes No

Partial Plate: Yes No

Stutter: Yes No

Coherent: Yes No

Was Polite: Yes No

Mumbled: Yes No

Roadside Conditions

Flat, Level Location: Yes No

Smooth Surface: Yes No

Leaves on Berm: Yes No

Shoulder/Berm: Yes No

Clean and Dry Surface: Yes No

Gravel and Rocks: Yes No

Surface Rough: Yes No

Surface Uneven/Cracked: Yes No

Sloping Road Surface: Yes No

Cars Speeding Fast: Yes No

Cars Causing Wind Gusts: Yes No

Revolving Police Lights: Yes No

Other Distractions: Yes No

Litter on Berm: Yes No

Stones and Pebbles: Yes No

Hilly Berm Surface: Yes No

Traffic: Yes No

Rain, Snow, Etc.: Yes No

Wig-Wag Police Lights: Yes No

On a Hill: Yes No

Broken Glass on Berm: Yes No

Photographs Available: Yes No

Motorist's Attire

Footwear

Cowboy Boots: Yes No

Loafers: Yes No

Opportunity to Remove: Yes No

High Heel Shoes: Yes No

Work Boots: Yes No

Flat/Normal Shoes: Yes No

Outer Garments

Tight Outer Coat: Yes No

Other: Yes No

Abnormal Performance Feats

In some instances the police officer will request that the motorist perform tests that many sober individuals have difficulty performing owing to age, weight, weather, roadside and other conditions. Please check each applicable box for each abnormal feat requested.

The Finger-to-Nose Test

Demonstrated: Yes No

Required to Close Eyes: Yes No

Touched Nose With Both Hands: Yes No

Location Touched:

Instructions Too Fast: Yes No

Understood Instructions: Yes No

Started When Told: Yes No

Completed Test as Asked: Yes No

Told Passed Test: Yes No

Told Failed Test: Yes No

Instructions Complicated: Yes No

Required to Tilt Head: Yes No

No Distractions: Yes No

Cars Speeding By: Yes No

Little/No Traffic: Yes No

Missed Nose: Yes No

Started Too Soon: Yes No

Officer Tilted Head Demonstrating: Yes No

Read Instructions: Yes No

The Heel-to-Toe Test

Demonstrated: Yes No

Entire Distance: Yes No

Surface Flat/Level: Yes No

Type of Shoes Worn:

Cars Speeding By: Yes No

Touched Heel to Toe: Yes No

Number of Steps Walked:

Stepped Off Line: Yes No

Followed Instruction: Yes No

Wrong Number of Steps: Yes No

Improper Turn: Yes No

Turned Properly: Yes No

Instructions Too Fast: Yes No

Understood Instructions: Yes No

Instructions Complicated: Yes No

Real Line: Yes No

Turn Demonstrated: Yes No

Imaginary Line: Yes No

Distractions Present: Yes No

Police Lights Going: Yes No

Missed Heel to Toe: Yes No

Swayed While Walking: Yes No

Started Too Soon: Yes No

Stumbled: Yes No

Stumbled Correct Number of Steps: Yes No

Told Failed Heel-to-Toe: Yes No

Told Passed Test: Yes No

Read Instructions: Yes No

The One Leg Stand Test

Understood Instructions: Yes No

Demonstrated: Yes No

Completed Test: Yes No

Unable to Do Test: Yes No

Duration Completed: Yes No

Where Officer Stood:

Flexed Knee: Yes No

Followed Instructions: Yes No

One Leg Stand Distractions: Yes No

Cars Speeding By: Yes No

Instructions Complicated: Yes No

Instructions Too Fast: Yes No

Duration Demonstrated: Yes No

Put Leg Down: Yes No

Swayed: Yes No

Required to Count: Yes No

Straight Object in Front of You: Yes No

Stumbled: Yes No

Started Too Soon: Yes No

Police Lights Going: Yes No

Instructions Read: Yes No

Number of Alcoholic Beverages Consumed

It is illegal for an adult to operate a motor vehicle in Pennsylvania with a blood alcohol reading above 0.08% or when a motorist is under the influence of alcohol to a degree that he cannot drive safely.

Usually a 180 lb. man is able to consume up to four beers or four one ounce drinks in a one hour period and not have a 0.10% blood alcohol. Thereafter, more than one drink per hour for every hour of drinking will result in a blood alcohol level above 0.10%. Please indicate the number of drinks consumed over what period of time:

Number Of Drinks:

Number Of Hours:

Own Opinion

Felt Drunk: Yes No

Told Officer Drunk: Yes No

Told Officer Not Drunk: Yes No

Felt Drove Safely: Yes No

Felt Not Drunk: Yes No

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D.U.I. Questionnaire

Personal Data

Prior D.U.I. Arrests

Condition of Motor Vehicle

Medical Condition

Weather and Road Conditions

Reason for Stop

Reasons For Possible Violation

Other Normal or Abnormal Driving By Motorist

Odor of Alcohol

Fumbling of Cards

The Motorist's Eyes

The Motorist's Speech

Roadside Conditions

Motorist's Attire

Footwear

Outer Garments

Abnormal Performance Feats

The Finger-to-Nose Test

The Heel-to-Toe Test

The One Leg Stand Test

Number of Alcoholic Beverages Consumed

Own Opinion

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