The following tabulated form is intended to help you see how damages include easily identifiable costs in an effort to place a dollar value on your physical person and the way in which your life has changed since you were injured. You should always have an inventory of known costs and make them obvious in your documents.

I.          Out-of-Pocket Damages a/k/a “Special Damages”

Damages Present                            Amount Spent or
in Case (U)                                          Estimated

Doctors’ bills                                         _____________                  $_________________

Ambulance bill                                     _____________                  $_________________

Hospital bills                                         _____________                  $_________________

Private nurses                                      _____________                  $_________________

Medicines/Drugs                                 _____________                  $_________________

Medical supplies                                  _____________                 $_________________

Travel/lodging arising from
need for medical treatment            _____________                  $_________________

Wheelchairs, walkers, prostheses,
handicapped-accessible vehicle,
other special implements                _____________                  $_________________

Future medical expenses                _____________                  $_________________

TOTAL MEDICAL DAMAGES   $_________________