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Pain and Suffering Statement Template
Explain how your accident-related injuries affect your body, mind, and daily life in a clear, organized statement.
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Pain and Suffering Statement Template
[Your Full Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
[Phone Number]
[Email Address]
Date of Birth: [MM/DD/YYYY]
1. Case and Incident Information
Type of Matter (check or describe):
Motor vehicle accident (may include DUI-related crash)
Workplace injury
Slip-and-fall / premises incident
Assault or violence
Medical or other personal injury
Other: [Describe]
Date of Incident: [MM/DD/YYYY]
Location of Incident (City, State/Province): [Location]
Insurance Company (if applicable): [Name]
Claim Number: [Number]
Attorney / Law Firm (if applicable): [Name]
File / Case Number: [Number]
2. Brief Description of the Incident
In this section, briefly explain what happened, in your own words. Do not argue about fault—just describe the event.
On [Date] at approximately [Time], in [Location], I was:
[Describe what you were doing just before the incident, e.g., “driving home from work,” “walking through a store,” “working at my job,” etc.]
The incident occurred when:
[Short factual description of what happened and how you were injured.]
3. Physical Pain and Symptoms
Describe the pain and physical symptoms you have experienced since the incident.
Injured body parts (list all):
[Example: neck, lower back, right shoulder, left knee, head, etc.]
Type of pain (describe):
[Example: sharp, aching, throbbing, burning, shooting, constant, on-and-off.]
Frequency of pain:
Constant
Several times per day
Daily
Several times per week
Occasional
Pain severity (0–10 scale; 0 = no pain, 10 = worst pain imaginable):
Average daily pain: [0–10]
Worst pain episodes: [0–10]
Explain how the pain feels in your own words, including when it is worst (for example, mornings, evenings, after walking, after sitting, during work):
[Free-text narrative]
4. Medical Treatment and Recovery Experience (High-Level Summary)
List the main types of treatment you have received and describe what the recovery process has been like for you.
Treatment received (check all that apply):
Emergency room visit
Urgent care or clinic visits
Primary care doctor
Specialist (orthopedic, neurologist, etc.)
Physical therapy / rehabilitation
Chiropractic care
Injections (pain management)
Surgery or procedures
Counseling or psychological support
Other: [Describe]
In your own words, describe:
How often you have had to attend medical appointments.
Any painful or difficult treatments or procedures.
Side effects of medications or treatment.
Sleep problems or fatigue related to pain or treatment.
Narrative:
[Free-text description of your treatment journey and how it has felt.]
5. Emotional and Psychological Impact
Describe how the incident and your injuries have affected your emotions and mental health.
Since the incident, I have experienced (check all that apply and describe):
Anxiety or fear (for example, about driving, falling again, being in crowds)
Sadness or depression
Irritability or anger
Difficulty concentrating or remembering things
Sleep problems, nightmares, or flashbacks
Loss of enjoyment in activities I used to like
Feeling embarrassed or self-conscious about my injuries or limitations
Other emotional effects: [Describe]
Describe in your own words how your mood, outlook, or personality have changed since the incident:
[Free-text narrative]
6. Impact on Daily Activities and Independence
Explain how your injuries affect your everyday life and independence.
Daily activities affected (check all that apply and briefly describe):
Getting in and out of bed or chairs
Bathing, grooming, or dressing
Using the bathroom
Cooking or preparing meals
Cleaning, laundry, and other housework
Shopping and errands
Driving or using public transportation
Caring for children, elderly family members, or pets
Managing appointments and daily tasks
Other: [Describe]
In your own words, describe specific examples of things you can no longer do or now do with difficulty, and how that makes you feel:
[Free-text narrative]
7. Impact on Work, School, and Financial Life
Explain how your injuries and suffering have affected your ability to work, study, and support yourself or your family.
Before the incident, my work or school situation was:
[Short description of your job, schedule, or studies.]
Since the incident (check all that apply):
I have missed work or school days.
I have returned with restrictions or light duty.
I cannot perform some of my usual tasks.
I have changed jobs or reduced hours.
I have stopped working or withdrawn from school.
Briefly describe how pain and other symptoms affect your work, studies, or income (for example, difficulty sitting or standing, lifting, focusing, meeting deadlines):
[Free-text narrative]
8. Impact on Relationships, Hobbies, and Quality of Life
Describe how your injuries have affected your family life, friendships, and ability to enjoy hobbies and activities.
Since the incident (check and describe):
I have been less able to participate in family activities or outings.
I have been less social or avoid friends and events.
I can no longer enjoy hobbies, sports, or exercise like before.
Pain or mood changes have caused tension or arguments at home.
Intimacy or closeness with my partner has been affected.
Other impacts on my relationships or enjoyment of life: [Describe]
In your own words, describe how your overall quality of life has changed compared to before the incident:
[Free-text narrative]
9. Prior Health and Changes Since the Incident
Briefly explain your general health and activity level before the incident, and how that compares with now.
Before the incident, my general health and activity level were:
[Describe, for example: “I was active, exercised regularly, worked full-time, and had no ongoing pain issues,” or explain any prior conditions.]
If you had any prior injuries or conditions to the same body parts, explain whether they were stable or resolved before this incident:
[Free-text explanation]
10. Closing Statement
Use this section to summarize, in your own words, how the accident and your injuries have affected you overall.
Closing summary (in your own words):
[Free-text paragraph or two explaining the overall impact on your life, what you hope will improve, and anything else you believe is important for the insurer, mediator, or court to understand.]
11. Declaration and Signature
I, [Your Full Name], declare that the information in this Pain and Suffering Statement is true and accurate to the best of my knowledge and describes my own experiences since the incident identified above. I understand that this statement may be used in connection with an insurance claim, settlement negotiations, or legal proceedings.
Signature: _______________________________
Printed Name: [Your Full Name]
Date Signed: [MM/DD/YYYY]
Place Signed (City, State/Province): [Location]
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Details
Learn more about
Pain and Suffering Statement Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
PAIN AND SUFFERING STATEMENT TEMPLATE FAQ
What is a pain and suffering statement?
A pain and suffering statement is a written, first-person description of how an accident or injury has affected you physically, emotionally, and in your day-to-day life. It is often used in insurance claims and personal injury cases to explain the non-economic impact of your injuries in your own words.
When is a pain and suffering statement used?
You may use a pain and suffering statement during settlement discussions with an insurance company, in a personal injury or DUI-related crash case, or when your lawyer asks you to describe what you have gone through. It can help adjusters, mediators, and courts understand more than just medical bills and lost wages.
What should I include in a pain and suffering statement?
A helpful pain and suffering statement usually includes: a brief summary of the incident, the type and level of physical pain you experience, your medical treatment and recovery process, emotional or psychological effects (such as anxiety, fear, or depression), changes to your work, family life, and hobbies, and what daily tasks are now harder or impossible for you.
How detailed should a pain and suffering statement be?
It should be honest, specific, and concrete, but not exaggerated. Describe the frequency and intensity of pain, real-life examples of things you struggle to do, how your mood and relationships have changed, and ways your life is different now compared to before the incident. Focus on facts and personal experience, not legal arguments or blame.
Is a pain and suffering statement legal advice, and do I need a lawyer?
No. A pain and suffering statement is your personal account of how you feel and how you have been affected. It is not legal advice, and writing one does not replace speaking with a lawyer. Because what you write may be used in negotiations or in court, many people choose to have a licensed attorney review their statement before it is submitted in a claim or lawsuit.
Can AI Lawyer help me write a pain and suffering statement?
Yes. AI Lawyer can help you organize your thoughts and put your experiences into clear, structured language using this template. You still need to provide truthful details about your own situation and carefully review the final statement. This template and any AI-generated content are for document organization only and are not legal advice—always consult a licensed attorney for guidance on your specific case.
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