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Name First Last
Email
Phone Number ### - ### - ####
Cell Phone Number ### - ### - ####
Date of Arrest MM / DD / YYYY
Town of Arrest
List medications you were taking on the date of your arrest:
Please check all boxes that apply. Your answers will assist us in developing the appropriate case strategy and providing you a detailed assessment of your case.

I suffer from acid reflux or another gastrointestinal condition. I suffer from any medical condition (back, neck, foot, toes, leg, ankle, hip, knee, joint, diabetes, eye disease, etc.) that could affect balance. I have an anxiety condition. I am flatfooted. I have a serious disease such as Seizures, Parkinson, M.S., R.A., vertigo, etc. that could cause the officer to mistake my symptoms for DWI. My field sobriety exercises conducted on a surface that was uneven, dimly-lit or unprotected from the wind. I was wearing contact lenses while taking the roadside tests. The officer’s overhead light shining direct towards me and the glare made me dizzy or otherwise obstructed my vision. The patrol car's lights, or lights from on-coming traffic, disoriented me when I performed the field sobriety exercises. When I did the walk and turn test, the officer used an actual line (opposed to an imaginary line). I had a cellular phone at the time of my arrest. The officer did not personally and directly watch me for at least 20 continuous minutes without interruption or distraction before the breath test. I had dentures during the breath test. I had a lip, tongue or other mouth piercing at the time of the breath test. I have gum disease. I was chewing tobacco or gum during the breath test. I had indigestion, burped, belched, or 'spit up' shortly before the breath test. I was working around chemical solvents, paints or paint-thinners on the day of my arrest? I have a minor speech impediment or unusual manner of speech. I have a hearing impediment. I smoke cigarettes. I have asthma. I have allergies I have one prior DWI conviction. I have two prior DWI convictions. I have three or more prior DWI convictions.
Do you have prior DWI convictions?
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