Date

Time

(Fill in the sections that apply)

Medical Treatment and Bills

❏ Doctors and other health care providers seen

❏ Treatments/Tests received

❏ Medical Expenses incurred

❏ Medications taken

Lost Income

❏ Hours of work missed

❏ Other lost income

Pain & Suffering

PHYSICAL PAIN

Location(s)

❏ Head

❏ Neck

❏ Low Back

❏ Shoulder, arm, wrist

❏ Leg, knee, foot

❏ Other

Severity

❏ Mild

❏ Moderate

❏ Severe

Type of pain

❏ Sharp

❏ Aching

❏ Soreness

❏ Shooting pain

❏ Stabbing pain

❏ Spasm

❏ Numbness

❏ Tingling

❏ Stiffness

Explain (including such things as what activities caused the pain and what activities made it better)

EMOTIONAL DISTRESS

Symptoms

❏ Sleep disturbed

❏ Eating difficulty

❏ Stress

❏ Embarrassment

❏ Depression

❏ Strained family relationships

❏ Other

Explain

MISSED OPPORTUNITIES AND OTHER EFFECTS ON YOUR LIFE

❏ Recreational activities

❏ Vacation

❏ Special Events (birthdays, weddings, graduations, funerals, etc.)

❏ Other effects

Explain

Evidence

❏ Photos

❏ Medical bills (including prescriptions)

❏ Disability Certificates (by doctor, authorizing missed work)

❏ Other