Loss of Enjoyment of Life Index - GA Injury Advocates

This form is to determine whether you have lost the enjoyment of certain activities in your life, or lost status or skills in these activities as a result of your injuries from this accident. This information is called “general damage’s” and is important part of your case. These details will be given to the insurance company to access how the accident affected your life and give value to your case.

Step 1 of 4

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Personal information

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

1. Pain & Suffering

a. What was the Date of the Incident?

a. What was the Date of the Incident (MM/DD/YY)?(Required)

MM slash DD slash YYYY

b. Progression of pain:

I. Rate your pain after the accident out of 10:

10 stars9 stars8 stars7 stars6 stars5 stars4 stars3 stars2 stars1 star

1/10 - Very little pain. 5/10 - Fair amount of pain. 10/10 - Worst pain imaginable.

II. Rate your current pain out of 10:

10 stars9 stars8 stars7 stars6 stars5 stars4 stars3 stars2 stars1 star

1/10 - Very little pain. 5/10 - Fair amount of pain. 10/10 - Worst pain imaginable.

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Current Date:

MM slash DD slash YYYY

c. Regarding day-to-day changes after the accident occurred:

I. What is the biggest difference in your life after the accident?

II. What is the biggest difference in the mornings after the accident?

III. What is the biggest difference during the day after the accident?

IV. What is the biggest difference in the evenings after the accident?

d. Describe the accident’s impact on your leisure and hobbies:

I. Activity 1: Name of affected activity (i.e., walks on the beach, hiking, painting, etc.).

Rate the impact of your injury on this activity:

5 stars4 stars3 stars2 stars1 star

1/5 - Can do it perfectly fine. 3/5 - Can do it with difficulty. 5/5 - Cannot do it at all.

ll. Activity 2: Name of affected activity (i.e., walks on the beach, hiking, painting, etc.).

Rate the impact of your injury on this activity:

5 stars4 stars3 stars2 stars1 star

1/5 - Can do it perfectly fine. 3/5 - Can do it with difficulty. 5/5 - Cannot do it at all.

III. Activity 3: Name of affected activity (i.e., walks on the beach, hiking, painting, etc.).

Rate the impact of your injury on this activity:

5 stars4 stars3 stars2 stars1 star

1/5 - Can do it perfectly fine. 3/5 - Can do it with difficulty. 5/5 - Cannot do it at all.

2. Work Related Activities

a. What was the name of your employer prior to the accident?

b. What was your job title prior to the incident?

c. My employment status at the time of the accident:

Full time

Part Time

Seasonal

Not Employed

Other

d. What was your salary/wage prior to the accident?

Per:

Hour

Day

Week

Month

Year

Self-Employed

e. What is the biggest difference during the workday after the accident?

f. An incident at work that never happened before the accident:

g. What happened to your employment after the accident? (Check all that apply)

I resumed the same job with the same duties

I resumed the same job with lighter duties

I resumed alternative duties with the same employer

I had to change employers

I had to change professions

I have not resumed work

h. How did the injuries sustained from the accident affect your work? (Check all that apply)

I have lost status within the company

I have lost job security (i.e., fewer hours, less overtime, etc.)

I have lost promotional prospects

I have difficulty in performing my normal job duties

My quality of work is reduced since the accident

I am unable to perform my pre-accident job

I have been terminated from my job for reasons related to my injuries.

i. How did the injuries sustained from the accident affect your work? (Check all that apply)

I have lost status within the company

I have lost job security (i.e., fewer hours, less overtime, etc.)

I have lost promotional prospects

I have difficulty performing my normal job duties

My quality of work is reduced since the accident

I am unable to perform my pre-accident job

I have been terminated from my job for reasons related to my injuries.

j. Did you experience any period of a total loss of income after the accident?

Not applicable.

I missed work (see range of dates below [1])

I have not returned to work since the accident but may be able to return to work (complete information below [2])

[1] I missed work from

MM slash DD slash YYYY

[2] I have not returned to work since the accident but may be able to return to work approximately on:

MM slash DD slash YYYY

[2] I have not returned to work since the accident but may be able to return to work...

I will return to the same work.

I will return to another job, with the same pay.

I will return to another job, with the lower pay (complete in [2.1]).

I will likely never be able to return to work.

[2.1] I will return to another job, with the lower pay at ____ [$]/[year]

k. Did you experience any partial loss of earning potential after the accident?

Not applicable.

I have returned to work, but... (continue in [3])

I suffered from reduced earnings from... (continue in [4])

[3] I have returned to work, but I earned $________ less per .....

[3] I have returned to work, but I earned $...... less per _______

[3] I have returned to work, but I earned less due to:

Being put on light duty

Working less hours

Working less overtime pay

Changing roles permanently

[4] I suffered from reduced earnings from

MM slash DD slash YYYY

l. Please rate the loss of enjoyment in performing your job as a result of the injuries caused by this accident:

10 stars9 stars8 stars7 stars6 stars5 stars4 stars3 stars2 stars1 star

1/10 - I have faced little change in the enjoyment of performing my job. 5/10 - I have lost a fair amount of enjoyment in performing my job. 10/10 - I no longer enjoy performing the job.

❖Please attach documentation to support any wages/time lost from work as a result of this accident.

Max. file size: 49 MB.

3. Household Activities

a. Which of the following household activities were disrupted? (Check all that apply)

Cleaning

Laundry

Dishwashing

Vacuuming

Preparing meals

Taking out the trash

Other

b. Which of the following outdoor activities were disrupted?

Mowing the grass

Landscaping

Trimming bushes

Gardening

Washing Cars

Other

c. How many children do you have?

d. Due to your injuries, have you brought in any of the following assistance?

Paid Housekeeper

Unpaid Assistance

None

e. Before the accident, I contributed ______ hrs a day on average to household activities.

f. After the accident, I contributed ______ hrs a day on average to household activities.

g. How long has your contribution to household services been impaired?

I experienced issues doing my normal household activities for ___ week (continue in [5]).

My doctors have instructed me that my inability to perform my normal pre-accident household activities without pain is a permanent condition.

My problems in performing my normal household activities are ongoing, but my doctors have not instructed me that the condition is permanent.

[5] I experienced issues doing my normal household activities for ___ week.

h. Describe an incident that occurred during the course of your domestic activities as a result of your injuries, that never happened before the accident (i.e., I had to hire a housekeeper; my husband now does all the cleaning; I have my niece come and clean my house because I am unable to clean).

4. Out-of-pocket Expenses

a. List all out-of-pocket expenses that you incurred as a result of the injuries you sustained that you would not have incurred otherwise?

Expense Type

Cost

Type of Supporting Documentation

❖Please attach supporting documentation for any expenses that you incurred as result of this accident

Max. file size: 49 MB.

5. Personal Statement

Name

This field is for validation purposes and should be left unchanged.

Personal information

1. Pain & Suffering

2. Work Related Activities

3. Household Activities

4. Out-of-pocket Expenses

5. Personal Statement

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