PRIMARY OBJECTIVE: The consequences of pre-morbid factors in adults with severe traumatic brain injury have not been widely addressed. This study aimed to determine whether being unemployed or on sick leave before injury influences long-term health-related quality-of-life (HRQoL) and functioning in patients with severe traumatic brain injury. SUBJECTS: Fifty-one consecutive patients were studied; aged 16-65 years, with severe traumatic brain injury who were admitted to Sahlgrenska University Hospital, Gothenburg, from 1999-2002. METHODS: The patients were assessed once, 2-11 years after trauma. Data from the time of injury were combined into a validated prognostic model to adjust for injury severity. Data on sick leave and unemployment before injury were gathered from the Swedish social insurance agency. Outcomes were measured with the Short Form-36 Health Survey, the Glasgow Outcome Scale-Extended, and a self-report questionnaire specifically designed for this study to measure functioning. RESULTS: In a multivariate analysis, a history of sick leave/unemployment predicted a worse long-term global outcome, more problems with personal activities of daily living and worse HRQoL. CONCLUSION: These results should be considered when refining outcome predictions and optimizing rehabilitation interventions for patients with severe traumatic brain injury.