Bucks County DUI Case Intake Form | Submit Your Bucks DUI Case

D.U.I. QUESTIONNAIRE Personal Data
Name:
Phone:
Email:
Date of Birth:
Age:
Address:
Height:
Weight:
City:
Zip:
Glasses or Contacts:
Prior D.U.I. Arrests:
Date:
Location:
Result:
Condition of Motor Vehicle
Make:
Model:
Year:
Number of Miles:
Condition of Vehicle:
Any Recalls:
Date Last Inspected:
Reason for Recall:
Any Mechanical Problems:
If Out of 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
On Any Prescriptions:	Yes No
Any Eye Problems:	Yes No
Recently to Dentist:	Yes No
Age:	Yes No
False Teeth:	Yes No
Recent Injury:	Yes No
Weight:	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
Roads Icy Approx.:	Yes No
Temperature:
Obstructions [List]:
Distractions [List]:
Gravel, Stones, Rocks:	Yes No
Line Worn Off Road:	Yes No
Reason for Stop An office 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.
Weaving:	Yes No
Crossing Center Line:	Yes No
Tailgating:	Yes No
Red Light Violation:	Yes No
Wrong Way on Street:	Yes No
If Told Reason Stopped:	Yes No
Travelling Too Slow:	Yes No
Going Off Road:	Yes No
Stop Sign Violation:	Yes No
Wrong Lane:	Yes No
Speeding:	Yes No
If Asked if Knew Reason Why Stopped:	Yes No
Wide Turn:	Yes No
Driving Off Road:	Yes No
Swerving:	Yes No
Headlights Off:	Yes No
Non-moving Violation:	Yes No
If Asked Why Weaving Occurred:	Yes No
Straddling Center:	Yes No
Other:
Reasons for Possible Violation
Too Many Drinks:	Yes No
Mechanical Problems:	Yes No
Adjusting Radio/Tape:	Yes No
Illness:	Yes No
Debris on Roadway:	Yes No
Using Handkerchief:	Yes No
Dropped Cigarette:	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:
Other Normal or Abnormal Driving by Motorist
Adjusted High Beams:	Yes No
Not Use Turn Signal:	Yes No
Not Use Flashers:	Yes No
Stopped at Safe Location:	Yes No
Car Drifted:	Yes No
Stopped in a Reasonable Distance:	Yes No
Stopped on Roadway:	Yes No
Pulled Off Road:	Yes No
Parked Over 6' Curb:	Yes No
Stopped Unlawful Spot:	Yes No
Stopped Promptly:	Yes No
Used Turn Signal:	Yes No
Used Flashers:	Yes No
Stopped Lawful Spot:	Yes No
Parked Parallel:	Yes No
Brake/Gears Used	Yes No
Police Chased:	Yes No
Stopped Reasonable Time:	Yes No
Parked 6' of Curb:	Yes No
Parked at an Angle:	Yes No
Stopped Unsafe Spot:	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, themere 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.
Diabetic:	Yes No
Concussion:	Yes No
Other:	Yes No
Beer Spilled on You:	Yes No
Recent Drinking:	Yes No
Non-alcoholic Beer:	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
If Told Speech Bad:	Yes No
False Teeth:	Yes No
Nervousness:	Yes No
Unknown:	Yes No
Answered All Questions:	Yes No
Speech Normal:	Yes No
If 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 Past:	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
If Demonstrated:	Yes No
Required to Close Eyes:	Yes No
If Officer Closed Eyes Strobing Police Lights 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
If Told Passed Test:	Yes No
If 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
If Officer Tilted Head Demonstrating:	Yes No
If Read Instructions:	Yes No
The Heel-to-Toe Test
If Demonstrated:	Yes No
Entire Distance:	Yes No
If Surface Flat/Level:	Yes No
Type of Shoes Wearing:
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
If Real Line:	Yes No
If Turn Demonstrated:	Yes No
If Imaginary Line:	Yes No
Any Distractions:	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
If Told Failed Test:	Yes No
If Told Passed Test:	Yes No
If Read Instructions:	Yes No
The One Leg Stand Test
Understood Instructions:	Yes No
If Demonstrated:	Yes No
If Completed Test:	Yes No
Unable to Do Test:	Yes No
Duration Completed:
Where Officer Stood:	Yes No
If Flexed Knee:	Yes No
Followed Instructions:	Yes No
Any Distractions:	Yes No
Cars Speeding By:	Yes No
Instructions Complicated:	Yes No
Instructions Too Fast:	Yes No
Duration Demonstrated:
If Put Leg Down:	Yes No
If Swayed:	Yes No
If Required to:	Yes No
Count:	Yes No
If Straight Object in Front of You:	Yes No
Stumbled:	Yes No
Started Too Soon:	Yes No
Police Lights Going:	Yes No
If 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
Feel Drunk:	Yes No
If Told Officer Drunk:	Yes No
If Told Officer Not Drunk:	Yes No
Feel Drove Safely:	Yes No
Feel Not Drunk:	Yes No

D.U.I. QUESTIONNAIRE