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

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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):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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

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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

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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.)?

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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? ____________________________________

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Finally, please comment on the impact the injury has had on your life and thelife of your family:

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