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]
