West Palm Beach Plaintiff's Checklist of Activities Affected by car accident Injury Call 1800-HURT-911

West Palm Beach Plaintiff's Checklist of Activities Affected by car accident Injury Call 1800-HURT-911

Activity Checklist

Instructions to client: Use the following checklist to indicate the activities which have been substantially limited, impaired, or affected by your injury. After each activity you check, list the name or names of the best witnesses who can testify about how the injury has affected the activity. Remem¬ber, the best witness would be someone who is objective, impartial, and who has had the opportunity to observe you in the activity both before and after your injury.

Affected Activity Name & Address Of Witness
Sports

_____ archery
_____ horseshoes
_____ softball
_____ baseball
_____ football
_____ running/jogging
_____ walking
_____ bowling
_____ down hill skiing
_____ cross country skiing
_____ swimming
_____ golf
_____ tennis
_____ hunting
_____ aerobics
_____ weight lifting
_____ biking
_____ camping
_____ horse back riding
_____ ATV riding
_____ badminton
_____ basketball
_____ squash
_____ racquetball
_____ parachuting
_____ rock climbing
_____ ice hockey
_____ ice skating
_____ roller skating
_____ in line skating (rollerblading)
_____ rafting
_____ canoeing
_____ snowmobiling
_____ jet skiing
_____ cricket
_____ table tennis
_____ wrestling
_____ wind surfing
_____ surfing
_____ boogie boarding
_____ snow boarding
_____ volleyball
_____ paddle ball
_____ handball
_____ high jumping
_____ discus throwing
_____ javelin throwing
_____ shooting
_____ rugby
_____ sit ups
_____ pushups
_____ yoga
_____ martial arts
_____ street hockey
_____ stickball
_____ soccer
_____ gymnastics
_____ snow shoeing

Hobbies And Other Activities

_____ using a pogo stick
_____ sewing
_____ crocheting
_____ knitting
_____ fishing
_____ bird watching
_____ painting
_____ photography
_____ playing musical instruments
_____ reading
_____ meditating
_____ camping
_____ paragliding
_____ bungee jumping
_____ Frisbee
_____ sailing
_____ motorcycling
_____ darts
_____ pool
_____ scuba diving
_____ snorkeling
_____ building models
_____ getting in and out of boats
_____ collecting coins, stamps, cards

Social Activities

_____ dancing
_____ going to antique shows
_____ going to flea markets
_____ eating out
_____ sightseeing
_____ going to the zoo
_____ going to museums
_____ going to parades
_____ going to the library
_____ walking
_____ driving cars
_____ entertaining
_____ meeting new people
_____ going on cruises
_____ visiting family or friends
_____ going to movies
_____ visiting tourist attractions
_____ going to amusement parks
_____ going on amusement rides
_____ going to parties
_____ singing
_____ attending church
_____ listening to music
_____ shopping
_____ vacations
_____ going to concerts
_____ games
_____ picnics
_____ attending barbecues
_____ going to the beach
_____ New Year's Eve activities
_____ New Year's Day activities
_____ Memorial Day activities
_____ Labor Day activities
_____ Yom Kippur activities
_____ Rosh Hashana activities
_____ Easter activities
_____ Hanukkah activities
_____ Christmas activities
_____ Halloween activities
_____ Mother's or Father's Day activities
_____ Thanksgiving Day activities
_____ Independence Day activities
_____ other holiday activities

Work Around The House

Cooking

_____ chopping
_____ dicing
_____ holding bowls
_____ making cakes or cookies
_____ stirring
_____ basting
_____ holding pans or pots
_____ slicing
_____ inserting leaves in table
_____ canning
_____ jarring
_____ baking
_____ pies
_____ mixing
_____ cutting
_____ pouring
_____ setting table
_____ lifting
_____ taking things out of freezer

Household Chores

_____ cleaning fans
_____ carrying pails of water
_____ folding laundry
_____ shampooing rugs
_____ polishing
_____ cleaning bathtub, sink, toilet
_____ painting
_____ spackling
_____ hanging paintings
_____ hammering
_____ sawing
_____ taking out trash
_____ walking dog
_____ repairing windows
_____ moving furniture
_____ starting a fire
_____ changing light bulbs
_____ installing fire alarms
_____ using fire extinguisher
_____ moving items into and out of attic or basement
_____ fixing leaks
_____ using a drill
_____ scraping walls
_____ fixing clogged toilet
_____ installing shelves
_____ arranging flowers
_____ putting in and taking out air conditioners
_____ hanging curtains, blinds
_____ putting in storm windows or screens
_____ getting mail
_____ changing batteries in smoke alarm
_____ setting clocks
_____ hooking up stereos, TVs, computers
_____ putting up holiday decorations
_____ picking up clothes, toys, etc.

Garden Chores

_____ mulching
_____ mowing grass
_____ weeding
_____ pruning
_____ fertilizing
_____ spraying
_____ watering lawn
_____ raking and bagging leaves
_____ tree climbing
_____ tree trimming
_____ pushing a wheelbarrow
_____ filling bird feeders
_____ cutting down trees
_____ cutting hay
_____ clearing brush and growth using a chainsaw

Other Outdoor Chores

_____ changing oil in car
_____ changing tires
_____ washing car
_____ cleaning exterior or interior of car
_____ chopping wood
_____ cleaning gutters
_____ climbing ladders
_____ putting up TV antennas
_____ climbing onto roofs
_____ using tools, such as screwdrivers or wrenches
_____ stacking wood
_____ putting in anti freeze
_____ fixing potholes in driveway
_____ cleaning pool
_____ pushing car out of snow
_____ shoveling driveway

Activities With Children

_____ birth
_____ carrying
_____ breast feeding
_____ bottle feeding
_____ feeding them at the table
_____ packing lunches
_____ bathing
_____ changing diapers
_____ dressing them
_____ washing their hands and faces
_____ shampooing, combing or drying their hair
_____ brushing their teeth
_____ toweling them dry
_____ teaching them
_____ driving them
_____ picking up toys
_____ pushing strollers
_____ picking up or hugging
_____ chasing
_____ disciplining
_____ putting or carrying them on shoulders
_____ carrying them in backpack
_____ rocking them
_____ tucking into bed
_____ holding or kissing
_____ playing
_____ looking at clouds
_____ taking to beaches or parks
_____ wrestling
_____ giving piggy back rides
_____ taking them to the movies, sports, parks, amusements
_____ coloring and painting with them
_____ teaching them to cook
_____ sports and activities

Personal Activities

Personal Hygiene

_____ toilet care
_____ bathing
_____ shampooing
_____ brushing teeth
_____ cutting toenails or fingernails
_____ gargling
_____ applying hair treatments
_____ putting on nail polish
_____ showering
_____ shaving
_____ flossing
_____ combing or brushing hair
_____ applying makeup
_____ cleaning ears
_____ applying deodorant

Dressing

_____ putting on clothes
_____ buttoning
_____ tying a tie
_____ tying shoes
_____ zippering
_____ putting on/taking off cuff links, bracelets, watches, necklaces,
etc.
_____ putting on and wearing boots

Eating

_____ chewing
_____ swallowing

Traveling

_____ carrying luggage
_____ driving a car
_____ getting in and out of car
_____ pumping gas
_____ walking on ice or uneven surfaces

Inter Personal

_____ sexual intercourse
_____ kissing
_____ feeling attractive
_____ flirting
_____ hugging
_____ caressing
_____ massaging
_____ touching

Physical Functions

_____ standing
_____ squatting
_____ bending to the side
_____ holding objects
_____ climbing
_____ sitting
_____ getting up
_____ scratching
_____ standing on one foot
_____ hopping
_____ jumping
_____ eating
_____ chewing
_____ standing on toes
_____ smelling
_____ running
_____ crouching
_____ bending over
_____ lifting
_____ kicking
_____ twisting
_____ lying down
_____ stretching
_____ touching toes
_____ doing a handstand
_____ skipping
_____ drinking
_____ smoking
_____ whistling
_____ tasting
_____ walking
_____ crawling

Emotional/ Psychiatric

_____ depression
_____ memory loss
_____ confusion
_____ irritability
_____ loneliness
_____ anger
_____ suicidal thoughts
_____ preoccupation
_____ nightmares
_____ hearing loss
_____ balance problems
_____ flashbacks
_____ spelling problems
_____ lack of sexual interest
_____ insecurity
_____ humiliation
_____ scarring
_____ anxiety
_____ shortened temper
_____ isolation
_____ fear
_____ self doubt
_____ worry
_____ obsession
_____ sweating
_____ visual problems
_____ lack of coordination
_____ can't find the right word
_____ phobias
_____ embarrassment
_____ paranoia

Miscellaneous

_____ writing
_____ dialing a telephone
_____ holding a telephone
_____ using a Dictaphone
_____ feeding a pet
_____ grooming and washing a pet
_____ wrapping presents
_____ carrying a purse
_____ getting up early
_____ avoiding danger
_____ going down slides
_____ using crutches
_____ holding a book, newspaper, etc.
_____ holding a mug
_____ carrying a briefcase
_____ sleeping
_____ typing
_____ using a channel changer
_____ using a computer
_____ kneeling to worship
_____ carrying groceries
_____ wearing high heels
_____ carrying umbrellas
_____ staying up late
_____ using a swing
_____ using a cane
_____ turning lights on and off
_____ winding a watch