DUI Intake Form

  • MM slash DD slash YYYY
  • Basic Arrest Info

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Pre-Arrest Handheld Breath Test (Pas)?
  • Did The Officer Accuse Of Being Under The Influence Of:
  • Basic Personal Data

  • Circumstances Surrounding The Stop

  • Search & Seizure:

  • Circumstances Of Arrest

  • STATEMENTS:

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Drinking Pattern Information

  • Drug Ingestion Information

  • For Each Medication/Drug Ingested, Do You Currently Have A Prescription:
  • For Each Medication/Drug Ingested, Have You Previously Had A Prescription:
  • Physical Condition

  • Do Any Of The Following Conditions Apply To You:

  • Condition Of Your Vehicle

  • Weather And Road Conditions

  • General Habits

  • Final Thoughts