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New Glasgow

134 Provost Street - PO Box 753


New Glasgow, Nova Scotia B2H 5G2
Tel: 902.755.0398 Fax: 902.755.2813

Halifax
6452 Quinpool Road
Halifax, Nova Scotia B3L 1A8
Tel: 902.404.3239 Fax: 902.755.2813

Toll Free: 1.888.434.0398


www.NSLegal.com

*Please direct all correspondence to New Glasgow office

LOSS OF VALUABLE SERVICES


AND 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:
(Please check one)

Single
Married
Common law
Separated
Divorced
Widowed

Number of children: Boys ______


Girls ______

Number of years:
Number of years:
Number of years:
Number of years:
Number of years:
Number of years:

__________
__________
__________
__________
__________
__________

Ages: _______________
Ages: _______________

PRE ACCIDENT STATUS


Pease describe what your life was like prior to the accident using the following
headings:
Your Employment Status:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Your Overall Health (Including any previous injuries):


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Your Hobbies/Interests/Sports/Volunteer Activities:


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Your Household Activities (Inside):


__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Your Household Activities (Outside):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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? Please


describe:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Has your relationship with your spouse/children/family been affected since


the accident? Please describe:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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 your
injury? YES _____ NO ______
Have you returned to work since the accident? (Please check as many as
apply)

Yes, full time, no change in duties


Yes, with modified hours
Yes, with modified duties
No

PRESENT DAY-TO-DAY FUNCTIONING


How long are you able to sit before having to get up and move around
because of pain?
__________________________________________________________________
__________________________________________________________________

How long are you able to stand before having to get up and move around
because 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 following
actions/activities on a scale from 1 to 10 (0= no difficulty; 10= severe difficultly)
Activity
0= no difficulty
10= severe difficultly
Bending Forward
0
1
2
3
4
5
6
7
8
9
10
Kneeling
0
1
2
3
4
5
6
7
8
9
10
Pushing
0
1
2
3
4
5
6
7
8
9
10
Pulling
0
1
2
3
4
5
6
7
8
9
10
Carrying
0
1
2
3
4
5
6
7
8
9
10
Squatting/Crouching 0
1
2
3
4
5
6
7
8
9
10
Balancing
0
1
2
3
4
5
6
7
8
9
10
Lifting
0
1
2
3
4
5
6
7
8
9
10
Reaching Overhead 0
1
2
3
4
5
6
7
8
9
10
Climbing stairs
0
1
2
3
4
5
6
7
8
9
10
Please provide details on how the above actions affect you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Please think about the following activities of your daily living. Then, put a
check mark under the category that best describes your present situation:
SELF CARE
Activity

Self Care

Check I am able to do this activity since my


here if injury, but I would describe my level of
you did difficulty as:
not do
this
activity
before
your
injury
Mild (I
Moderate Severe (I have
have little (I have
considerable
or no
some
difficulty all
difficulty) difficulty
of the time,
most of the and need help
time, and
from others)
it takes me
longer to
do this
now)

I am
completely
unable to
do this
activity
since my
injury

Unable to
do this
activity

Daily
Grooming
Washing Hair
Bathing
Shower
Dressing
Shaving

From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

HOUSEHOLD ACTIVITIES
Activity

Household
Activities

Check
here if
you did
not do
this
activity
before
your
injury

I am able to do this activity since my


I am
injury, but I would describe my level of completely
difficulty as:
unable to
do this
activity
since my
injury

Mild (I
have little
or no
difficulty)

Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)

Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)

Sweeping
Vacuuming
Mopping
Laundry
Washing/Drying
dishes
Making beds
Changing bed
sheets
Preparing meals
Cleaning the
Oven

Grocery
Shopping
Fall/Spring
Cleaning
Cleaning
Windows
Interior House
Painting
Cleaning
Tub/Toilet
Dusting
Taking out
Garbage
Ironing
Wood Stacking
or Splitting
(Wood Stove)
From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

EXTERNAL HOME MAINTENANCE


Activity

External Home
Maintenance
(Outside the
house)

Check
here if
you did
not do
this
activity
before
your
injury

I am able to do this activity since my


injury, but I would describe my level
of difficulty as:

Mild (I
have little
or no
difficulty)

Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)

I am
completely
unable to
do this
activity
since my
injury

Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)

Gardening
House
Repairs/Maintena
nce
Snow Shoveling
Exterior House
Painting
Lawn Mowing
Raking Leaves
Spring/Fall Clean
up
Chimney
Cleaning
Car repairs/
Maintenance
Car cleaning
Driving a car

From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

10

SOCIAL/RECREATIONAL
Activity

Social/
Recreational

Check
here if
you did
not do
this
activity
before
your
injury

I am able to do this activity since my


injury, but I would describe my level
of difficulty as:

Mild (I
have little
or no
difficulty)

Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)

I am
completely
unable to
do this
activity
since my
injury

Severe (I
Unable to
have
do this
considerable activity
difficulty all
of the time,
and need
help from
others)

Socializing with
friends
Visiting with
Family
Taking part in
sports
Watching sports
Engaging in
hobbies
Reading
Going to movies
Using a computer

From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

11

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Child care
Activity

Child care

Check
here if
you did
not do
this
activity
before
your
injury

I am able to do this activity since my


injury, but I would describe my level of
difficulty as:

I am
completely
unable to do
this activity
since my
injury

Mild (I
have little
or no
difficulty)

Unable to
do this
activity

Moderate
(I have
some
difficulty
most of
the time,
and it
takes me
longer to
do this
now)

Severe (I
have
considerabl
e difficulty
all of the
time, and
need help
from
others)

Supervision
and play
Driving to
activities
Caring for an
ill child
Diapering and
toileting

12

From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Pet Care
Activity

Pet Care

Check
here if
you did
not do
this
activity
before
your
injury

I am able to do this activity since my


injury, but I would describe my level of
difficulty as:

I am
completely
unable to
do this
activity
since my
injury

Mild (I
have little
or no
difficulty)

Unable to
do this
activity

Moderate
(I have
some
difficulty
most of the
time, and
it takes me
longer to
do this
now)

Severe (I
have
considerable
difficulty all
of the time,
and need
help from
others)

Grooming
Bathing
Walking

13

From the above list, please identify the activities you can do with help and indicate
the person who helps you:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

From the above list, please identify the activities that you rely on others to do
entirely and indicate who does them:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

MEDICATIONS
Please list the medications that you are presently taking as a result of your
injury. (Do not list medications that are not related to your injury). Please
list the prescription and non-prescription medication(s), the dosages, and how
many times a day you take each medication.
Prescription medications I am presently taking
Full Name of Medication Dosage (typically in mg.)

How many times a day is


the medication prescribed
for you to take? (E.g.
three times a day)

Over the counter medications I am presently taking


Type of Medication
How much you spend per Did any particular person
month?
recommend this
medication to you (e.g.
friend, family doctor,
etc.)?

14

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 your
home _____
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 the
life of your family:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

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