Injury Diary Template printable pdf download

INJURY DIARY

INSTRUCTIONS: It is important in this case to be able to show the adjuster exactly how your

injuries affect you on a daily basis. Write in only your actual symptoms [or, if

you are a family member, your actual observations]. Do not exaggerate, as that could be harmful

to the claim

Claimant ________________________

Individual completing the diary _________________________

Relationship to claimant _____________________

DATE ___________________

MORNING:

_________________________________________________________________________________

____________________________________

AFTERNOON:

___________________________________________________________________________

______________________________________________________________________________

_______________________________________________________

EVENING:

___________________________________________________________________________

______________________________________________________________________________

_______________________________________________________________

NIGHT:

___________________________________________________________________________

______________________________________________________________________________

_______________________________________________________

SAMPLE DIARY: This is a sample only.

Morning:

Could not sleep all night. Got out of bed at 3:00 a.m. and sat in recliner as it was more

comfortable. I had to use a cane to get from the bed to recliner. Fell in the bathroom.

Got out of bed at 8:00 a.m. Made coffee but right arm weak and dropped the coffee cup and

Tried to balance my checkbook but got frustrated because I could not concentrate and had to

stop. Took a nap at 10:00 a.m. for 2 hours and felt a little better. Took a pain pill.

Injury Diary Template