Joliet DUI Questionnaire

This is an extensive questionnaire that will take some time to completely finish. You can browse through the questions by clicking on the next page button at the bottom of each page. All information is kept confidential.

IMPORTANT: We suggest that any long answers to important questions are saved by you on a separate document in case you lose your internet connection while completing this form. Then copy and past the text into the form answer blank.

Each questionnaire response box needs an answer of at least Yes or No

Step 1 of 14

Do you have a logical explanation for why you were stopped? If yes, what is it?
Did you pull over and stop immediately and appropriately? If no, do you have a logical explanation for not doing so? What is the explanation?
Were you tired or fatigued at the time of the stop?
How much sleep did you have the night before the stop?
Were you nervous at the time of the stop?
Do you have any speech impediments? If yes, what?
Is English your native language? If no, what is?

Were you mad or upset at the time of the stop? If yes, why?
Were you chewing gum at the time of the stop?
How long before the stop did you last use mouthwash?
How long before the stop did you last take any cold medication? If recent, what did you take?
Was any alcohol spilled on you? If yes, explain.
Was any alcohol spilled indoor car? If yes, explain.
Was there an open container of alcohol in your car? If yes explain.

Were there passengers in your car? If yes, how many passengers had been drinking?
Did you have any trouble answering the officer's questions? If yes, why did you have difficulty?
Did you have any trouble producing the requested documents? If yes, why?
Did the officer ask you to recite the alphabet?
Do you know your alphabet?
Were you still sitting in your vehicle when you were asked to recite the alphabet? If no, where were you?
Did the officer tell you to not sing the alphabet song while reciting the alphabet?
Were you asked to recite the whole alphabet or only part of the alphabet? If only part, what were the starting and stopping letters that the officer used.
Did the officer ask you to count backwards?
Can you normally count backwards? If no, why?

Do you have any back problems? If yes, what?
Do you have inner ear problems or disorders? If yes, what?
Do you have any leg, knee, or ankle problems? If yes, what are they?
Do you have natural nystagmus in your eyes? If yes, what is it and has it been medically diagnosed?
Were you in a rollover accident right before the police arrived?
Was you driver's window down while you were driving?
What was the approximate outside temperature at the time of the stop?
What was the approximate temperature inside your vehicle at the time of the stop?
Did the officer have you preform the HGN (eye) Test?
Were you sitting down during the HGN (eye) Test? If yes, where were you sitting?

Were you standing in front of the patrol car during the HGN (eye) Test? If no, where were you?
Did the officer leave his forward-facing emergency lights on during the HGN (eye) Test?
Were there any other patrol cars at the scene? If yes, did they leave their forward-facing emergency lights on during the HGN (eye) Test?
Were you stopped in a construction zone? If yes, did the construction vehicles have their emergency lights on during the HGN (eye) Test?
During the HGN (eye) test, was an ambulance at the scene?
During the HGN (eye) test, was a fire truck at the scene?
Did a tow truck arrive during the HGN (eye) test?
During the HGN (eye) test, did a street sweeper drive by the stop location?
Were any streetlights flickering or malfunctioning during the HGN (eye) test? If yes, where were they and what were they doing?
Were you facing passing traffic during the HGN (eye) test? If yes, approximately how many cars passed by and approximately how fast were they going?

Do you have a brain tumor? If yes, explain.
Do you have brain damage? If yes, explain.
Do you have any diseases of the inner ear? If yes, explain.
Do you have any medical conditions? If yes, what?
Were you wearing glasses at the time of the stop?
Did the officer have you remove your glasses for the HGN (eye) test?
Did the officer have you put your glasses back on for the walk and turn and one leg stand tests?
Is your left pupil normally larger or smaller than your right pupil? If yes, explain.
At the time of your stop, was your left pupil larger or smaller than your right pupil? If yes, explain

Do your eyes track back and forth equally? If no, explain.
Do your eyes normally jerk or have nystagmus when you look straight ahead? If yes, explain.
Do you have any eye disorders? If yes, what?
Did the officer have you perform the walk and turn test?
For the walk and turn test did you use a real or imaginary line?
For the walk and turn test, was the surface where the test was conducted dry, hard, level, and non-slippery? If no, explain.
For the walk and turn test, was there enough room for you to complete mine steps? If no, explain.
Were you 60 years of age or older on the day of the arrest? If yes, how old were you?
Were you 50 or more pounds overweight on the day of the arrest? If yes, how many pounds overweight?

Do you have any back, leg, or middle ear problems? If yes, explain.
Was the weather bad at the time of the stop? If yes, explain.
Were you wearing high heels, sandals, flip-flops, cowboy boots, costume shoes, or flat-soled shoes at the time of the stop? If yes, explain.
Did you remove your footwear for the walk and turn and the one leg stand test? If yes, were you in socks or bare feet for the tests? Explain?
Did the officer have you perform the one leg stand test?
For the one leg stand test, was the surface where the test was conducted dry, hard, level, and non-slippery? If no, explain.
At the scene of the traffic stop, did you take a portable or preliminary breathe test using a handheld device?
Did you refuse to take a take a portable or preliminary breathe test at the scene of the traffic stop? If yes, why did you refuse?
If you took the portable or preliminary breathe test, did the officer constantly observe you for at least 20 minutes prior to this test? If no, explain.

Did you burp, belch, vomit or regurgitate within 20 minutes of taking the portable or preliminary breathe test? If yes, explain.
Did the portable or preliminary breathe testing machine appear to malfunction during this incident? If yes, explain.
Did you take any prescription medications within 24 hours of the stop? If yes, did you take the prescribed dosages? What did you take and how long before the stop did you last take the medication(s).
If last medications used were taken more than 24 hours prior to the stop, what did you take when did you last take the medications?
Did you take any illegal drugs within 24 hours prior to the stop? If yes, what drugs did you take, how long before the stop did you last take the drug(s), and how did you ingest the drug(s)?
If the last illegal drugs used were taken more than 24 hours prior to the stop, what did you take and when did you last take the illegal drugs?

Can you normally cross your eyes?
Are your pupils normally large or small? If yes, explain.
Is your blood pressure normally high or low? If yes, explain.
Were you sick or ill at the time of your stop? If yes, explain.
Is there any reason why your body temperature would have been high or low at the time of the stop? If yes, explain.
Do you regularly exercise and/or lift weights? If yes, explain.
Were you extremely fatigued at the time of the stop? If yes, explain?

Have you had any recent head injuries? If yes, explain?
Do you have Hypotension (lowering of the blood pressure)?
Were you severely depressed at the time of the stop? If yes, explain?
Are you a diabetic?
Do you take insuin?
Were you experiencing a diabetic reaction at the time of the stop? If yes, please explain.
Are you hyperactive?
Were you stressed at the time of the stop? If yes, explain?
Were you afraid at the time of the stop? If yes, explain?
Do you have Hypertension (high blood pressure)?

Do you have mental illness or amy mental disorders? If yes, explain.
Did you have a high fever at the time of the stop? If yes, explain.
Do you have ADD? If yes, please explain.
Had you recently consumed any green colored drinks, foods, candy or gum? If yes, explain.
Did you drink any alcohol within 12 hours of they stop?
What specific drinks did you have?
How many drinks did you have?
What was the size of the drinks?
At what time did you have your first drink?

At what time did you have your last drink?
At what time did you last eat?
What did you have to eat?
How much did you eat?
On the day of the arrest, how much did you weigh?
If you took a breath test at the Jail or the Police Department, did there appear to be anything wrong with the breathe testing machine. If yes, explain?
How many breath samples did you provide.
Is there any reason why your body temperature may have been high at the time of the time of the breathe test? If yes, explain?
Did the officer tell you to take a deep breath and did you hold the air in your mouth for few seconds prior to blowing into the breath testing machine? If yes, explain?
Did the officer have you keep blowing and blowing until you were about to gasp out your last amount of breath? If yes, explain?
Do you were dentures?

Within 12 hours of the breath test had you used or been around ethylene, toluene, nitrous oxide, diethyl ether, acetonitrile, isopropanel, or any other similar substances or chemicals. If yes, explain?
Are you on a low carb diet. If yes, explain?
Were you experiencing a diabetic reaction at the time of the breath test? If yes, explain?
Did you submit for a blood test?
Who took your blood sample and where were you at when the sample was taken?
Do you know what substance was used to clean your arm prior to your blood sample being taken? If yes, explain?
Did you refuse a breath test? If yes, why?
Did you refuse a blood test? If yes, why?
Did you refuse a urine test? If yes, why?
Do you have many additional useful information that has not been covered in the above questions? If yes, explain?
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