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): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2 .

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: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 3 .

full time. with modified duties No 4 . no change in duties Yes.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. with modified hours Yes.

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: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 5 .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.

Please think about the following activities of your daily living. 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. most of the and need help time. please identify the activities you can do with help and indicate the person who helps you: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 6 . 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. 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.

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 7 . 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.From the above list. 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.

please identify the activities that you rely on others to do entirely and indicate who does them: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 8 .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.

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 9 . 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.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.

From the above list. please identify the activities that you rely on others to do entirely and indicate who does them: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 10 . please identify the activities you can do with help and indicate the person who helps you: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ From the above list.

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 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. 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. please identify the activities you can do with help and indicate the person who helps you: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 11 .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.

From the above list. 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. 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. 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 .

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. and it takes me longer to do this now) Severe (I have considerable difficulty all of the time.From the above list. please identify the activities you can do with help and indicate the person who helps you: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ From the above list. and need help from others) Grooming Bathing Walking 13 . 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.

friend. family doctor.) How many times a day is the medication prescribed for you to take? (E. 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.From the above list.g.g. Please list the prescription and non-prescription medication(s). please identify the activities you can do with help and indicate the person who helps you: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ From the above list. etc. 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.)? 14 . the dosages. Prescription medications I am presently taking Full Name of Medication Dosage (typically in mg. (Do not list medications that are not related to your injury). and how many times a day you take each medication.

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? ____________________________________ 15 .

please comment on the impact the injury has had on your life and the life of your family: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 16 .Finally.

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