Life Impact Survey


QUALITY OF LIFE IMPACT

1. Injuries
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2. Pain

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



CURRENT FREQUENCY

3. Physical Limitations

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




















4. Physical Leisure Activities Affected

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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

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What social activities have you had to reduce or abandon?
SOCIAL ACTIVITY









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



YesNo


7. School/Work Loss
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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
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9. Quality of Life Witnesses
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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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