loss of valuable services and housekeeping questionnaire 1
Post on 07-Oct-2014
18 Views
Preview:
TRANSCRIPT
LOSS OF VALUABLE SERVICESAND HOUSEKEEPING QUESTIONNAIRE
Privileged Solicitor-Client Work Product
PERSONAL DATA
Name: _______________________________
Address: _______________________________________________________________________________________ Postal code: __________
Phone: (H) ___________________________ (W) _______________________Email address: ____________________________________________________Date of Birth: (Month) __________ (Day) __________ (Year) __________
Present Marital Status: Single Number of years: __________(Please check one) Married Number of years: __________
Common law Number of years: __________Separated Number of years: __________Divorced Number of years: __________Widowed Number of years: __________
Number of children: Boys ______ Ages: _______________Girls ______ Ages: _______________
New Glasgow134 Provost Street - PO Box 753New Glasgow, Nova Scotia B2H 5G2Tel: 902.755.0398 Fax: 902.755.2813
Halifax6452 Quinpool RoadHalifax, Nova Scotia B3L 1A8Tel: 902.404.3239 Fax: 902.755.2813
Toll Free: 1.888.434.0398www.NSLegal.com *Please direct all correspondence to New Glasgow office
2
PRE ACCIDENT STATUS
Pease describe what your life was like prior to the accident using the followingheadings:
Your Employment Status:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your Overall Health (Including any previous injuries):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your Hobbies/Interests/Sports/Volunteer Activities:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your Household Activities (Inside):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Your Household Activities (Outside):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3
INJURY INFORMATION
Date of Accident: __________________________________________________
What were your injuries at the time of the accident?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your sleep been affected since the accident? Please describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your overall mood been affected since the accident? Please describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your memory/concentration been affected since the accident? Pleasedescribe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has your relationship with your spouse/children/family been affected sincethe accident? Please describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4
VOCATIONAL INFORMATION
Education Level Completed: _________________________________________Name of School: ___________________________________________________What year did you finish your schooling? ______________________________
Your Occupation:
At the time of the accident: ____________________________________ At the present time: __________________________________________
Your Employer:
At the time of the accident: ____________________________________ At the present time: __________________________________________
How long did you work for your most recent employer? _________________
Please provide a brief description of your job responsibilities:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Has an Occupational Therapist visited your home or worksite since yourinjury? YES _____ NO ______
Have you returned to work since the accident? (Please check as many asapply)
Yes, full time, no change in duties Yes, with modified hours Yes, with modified duties No
5
PRESENT DAY-TO-DAY FUNCTIONING
How long are you able to sit before having to get up and move aroundbecause of pain?____________________________________________________________________________________________________________________________________
How long are you able to stand before having to get up and move aroundbecause of pain?____________________________________________________________________________________________________________________________________
How long are you able to walk without the need to rest?____________________________________________________________________________________________________________________________________
Please indicate the degree of difficulty you may have with the followingactions/activities on a scale from 1 to 10 (0= no difficulty; 10= severe difficultly)Activity 0= no difficulty
10= severe difficultlyBending Forward 0 1 2 3 4 5 6 7 8 9 10Kneeling 0 1 2 3 4 5 6 7 8 9 10Pushing 0 1 2 3 4 5 6 7 8 9 10Pulling 0 1 2 3 4 5 6 7 8 9 10Carrying 0 1 2 3 4 5 6 7 8 9 10Squatting/Crouching 0 1 2 3 4 5 6 7 8 9 10Balancing 0 1 2 3 4 5 6 7 8 9 10Lifting 0 1 2 3 4 5 6 7 8 9 10Reaching Overhead 0 1 2 3 4 5 6 7 8 9 10Climbing stairs 0 1 2 3 4 5 6 7 8 9 10
Please provide details on how the above actions affect you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
6
Please think about the following activities of your daily living. Then, put acheck mark under the category that best describes your present situation:
SELF CARE
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my level ofdifficulty as:
I amcompletelyunable todo thisactivitysince myinjury
Self Care Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost of thetime, andit takes melonger todo thisnow)
Severe (I haveconsiderabledifficulty allof the time,and need helpfrom others)
Unable todo thisactivity
DailyGroomingWashing HairBathingShowerDressingShaving
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HOUSEHOLD ACTIVITIES
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my level ofdifficulty as:
I amcompletelyunable todo thisactivitysince myinjury
HouseholdActivities
Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost ofthe time,and ittakes melonger todo thisnow)
Severe (Ihaveconsiderabledifficulty allof the time,and needhelp fromothers)
Unable todo thisactivity
SweepingVacuumingMoppingLaundryWashing/DryingdishesMaking bedsChanging bedsheetsPreparing mealsCleaning theOven
8
GroceryShoppingFall/SpringCleaningCleaningWindowsInterior HousePaintingCleaningTub/ToiletDustingTaking outGarbageIroningWood Stackingor Splitting(Wood Stove)
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9
EXTERNAL HOME MAINTENANCE
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my levelof difficulty as:
I amcompletelyunable todo thisactivitysince myinjury
External HomeMaintenance(Outside thehouse)
Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost ofthe time,and ittakes melonger todo thisnow)
Severe (Ihaveconsiderabledifficulty allof the time,and needhelp fromothers)
Unable todo thisactivity
GardeningHouseRepairs/MaintenanceSnow ShovelingExterior HousePaintingLawn MowingRaking LeavesSpring/Fall CleanupChimneyCleaningCar repairs/MaintenanceCar cleaningDriving a car
10
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
11
SOCIAL/RECREATIONAL
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my levelof difficulty as:
I amcompletelyunable todo thisactivitysince myinjury
Social/Recreational
Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost ofthe time,and ittakes melonger todo thisnow)
Severe (Ihaveconsiderabledifficulty allof the time,and needhelp fromothers)
Unable todo thisactivity
Socializing withfriendsVisiting withFamilyTaking part insportsWatching sportsEngaging inhobbiesReadingGoing to moviesUsing a computer
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
12
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Child care
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my level ofdifficulty as:
I amcompletelyunable to dothis activitysince myinjury
Child care Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost ofthe time,and ittakes melonger todo thisnow)
Severe (Ihaveconsiderable difficultyall of thetime, andneed helpfromothers)
Unable todo thisactivity
Supervisionand playDriving toactivitiesCaring for anill childDiapering andtoileting
13
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Pet Care
Activity Checkhere ifyou didnot dothisactivitybeforeyourinjury
I am able to do this activity since myinjury, but I would describe my level ofdifficulty as:
I amcompletelyunable todo thisactivitysince myinjury
Pet Care Mild (Ihave littleor nodifficulty)
Moderate(I havesomedifficultymost of thetime, andit takes melonger todo thisnow)
Severe (Ihaveconsiderabledifficulty allof the time,and needhelp fromothers)
Unable todo thisactivity
GroomingBathingWalking
14
From the above list, please identify the activities you can do with help and indicatethe person who helps you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
From the above list, please identify the activities that you rely on others to doentirely and indicate who does them:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MEDICATIONS
Please list the medications that you are presently taking as a result of yourinjury. (Do not list medications that are not related to your injury). Pleaselist the prescription and non-prescription medication(s), the dosages, and howmany times a day you take each medication.
Prescription medications I am presently takingFull Name of Medication Dosage (typically in mg.) How many times a day is
the medication prescribedfor you to take? (E.g.three times a day)
“Over the counter” medications I am presently takingType of Medication How much you spend per
month?Did any particular personrecommend thismedication to you (e.g.friend, family doctor,etc.)?
15
Did you take any of these medications before your injury?YES _____ NO _____If yes, please list below:____________________________________________________________________________________________________________________________________
GENERAL INFORMATION
Financial:
What is your present source of income? (Check all that apply)
Wages from Employment Employment Insurance Long Term Disability Canada Pension Disability Section “B” Loss of Wages Benefits Social Assistance Guaranteed Income Supplement Spousal Support
Description of Home:
Do you own or rent your present home? Own _____ Rent _____
How long have you lived at this location?__________________________________________________________________
Number of bedrooms in your home _____ Number of bathrooms in yourhome _____
How many levels does you home have? ________________________________What size lot is your house on? _______________________________________On what level are your laundry facilities? ______________________________Do you have a finished basement? ____________________________________
16
Finally, please comment on the impact the injury has had on your life and thelife of your family:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
top related