Protecting Accident Victims Since 1983

Life Impact Survey


1. Injuries

2. Pain

Please describe in detail any pain which you have experienced because of the accident, and the current frequency of the pain:


3. Physical Limitations

What effect have your injuries had on your physical ability to do the following:

4. Physical Leisure Activities Affected

Before this accident, what sort of specific leisure activities did you regularly enjoy doing after work or outside the home? Please indicate specific activity, such as bowling, skiing, gardening, hunting, etc., and how often before the accident you would normally take part in such activities and how often you do so now.

5. Social Activities

What social activities have you had to reduce or abandon?

6. Home Confinement
label>Were you ever confined to bed at home as a result of this accident:


7. School/Work Loss
If you were attending school at the time of the accident and lost time from school, please provide the dates you lost time from school due to your accident injuries.

8. Other Difficulties

9. Quality of Life Witnesses
Please provide the name of anyone (include members of your family, neighbors, friends) who may know what effect your accident injuries have had on your hobbies, activities or physical condition in general:

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