Non-Economic Damage Worksheet

A major component to any personal injury case is what we call non-economic damages. Please
fill out the form and explain if this injury has caused you any of the following harms. Please use
the information and format under Physical pain as a template to guide you on how to fill out
each of the following. Youre entitled to separate compensation for each of the listed damages, if
in fact you suffered them.

There are guide words listen under certain damages that are there in order to help spark. You may
have suffered these, or other damages. These are merely examples and are in no way an
exhaustive list.

For the purposes of this section, the term "non-economic damages" means subjective, non-
monetary losses including, but not limited to, pain, suffering, inconvenience, mental suffering,
emotional distress, loss of society and companionship, loss of consortium, injury to reputation
and humiliation.

Please give examples of how you suffered the following:

Physical pain

I suffered pain in my back and neck.

Timeline

1/1/2017 6/30/17

The pain in my back was a constant 8-9

7/1/17 Present

I feel a stabbing pain around 3 days per week. During those days, the pain is present for
approximately 3 hours per day.

Specifics

The pain peaks when Ive been standing at work for 2 or more hours. I usually have to stand for
about 5 hours, Monday through Friday.

It also is especially bad while I sleep. I wake up approximately 2-3 times every night, and it takes
me about 45 minutes to fall back asleep.

Instances which others can testify to (signed letters highly recommended)

My boss, Steve, has noticed that my work productivity has decreased significantly. I was written
up at work and have a copy.
My boyfriend Robert and I cannot go jogging together anymore.

My friend Jim and I had to cancel a trip to Europe that we had scheduled because it would
involve too much walking, which I am unable to.

Physical Suffering

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Inconvenience

Missing work, spending time going to appointments, etc.

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Mental Suffering

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Emotional Distress

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Grief

Definition deep sorrow

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Anxiety

Definition - a feeling of worry, nervousness, or unease, typically about an imminent event or

something with an uncertain outcome

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Loss of society and companionship

Unable to go out with friends, missing trips or events,

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Loss of enjoyment of life

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Disfigurement

Any change in ones appearance, whether temporary or permanent. (bruise, broken bone, etc.)

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Loss of consortium (how has this affected your significant other)

NOTE: If possible, do not shy away from discussing how this injury has caused you a reduction
in sexual interaction, if in fact it has. Although it is usually a private matter that is not to be
discussed, if the injury is affecting or prohibiting your sexual interaction, you deserve to be
compensated for it and it will add value to your claim. This is at your own discretion and we
respect your right to forego

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Injury to reputation

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended)

Humiliation

Fell in front of everyone, taken on stretcher, doctors and nurses operating on body

Timeline

Specifics

Instances which others can testify to (signed letters highly recommended