Form SSA-3373-BK, Function Report - Adult Completed Form Examples and Samples

Explore comprehensive examples of a filled-out Form SSA-3373-BK, the Function Report - Adult. Our detailed samples demonstrate how to accurately describe daily limitations for a Social Security disability claim, helping you complete the form effectively.
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Completed Form SSA-3373-BK, Function Report - Adult, for a claimant with severe rheumatoid arthritis.

Form SSA-3373-BK Example – Adult with Rheumatoid Arthritis

How this form was filled:

This is a sample Form SSA-3373-BK, Function Report - Adult, filled out for an individual with severe rheumatoid arthritis and associated cognitive difficulties. The example demonstrates how to describe daily limitations, pain, fatigue, and the need for assistance in a clear and detailed manner, which is crucial for a Social Security disability claim.

Information used to fill out the document:

  • Claimant Name: Jane M. Smith
  • Social Security Number: 987-XX-4321
  • Primary Illnesses/Conditions: Severe Rheumatoid Arthritis, Cognitive Fog ('Brain Fog')
  • Date of Form Completion: 02/10/2026
  • Date Condition Began Affecting Function: 01/15/2024
  • Living Arrangement: Lives alone in a first-floor apartment
  • Personal Care Limitations: Needs help with buttons/zippers, uses a shower chair, cannot style hair due to shoulder/hand pain. Tasks are exhausting.
  • Meal Preparation Difficulties: Prepares only simple/microwave meals. Cannot chop vegetables or open jars. Drops items frequently due to hand weakness.
  • Mobility Issues: Walks up to 50 feet with a cane before needing to rest. Cannot use public transit. Drives only short distances on 'good' days.
  • Housekeeping Capacity: Performs only very light tasks like wiping counters. Sister assists weekly with laundry, vacuuming, and heavy cleaning.
  • Cognitive Challenges: Experiences 'brain fog,' leading to trouble concentrating, forgetting appointments, and losing track of conversations.
  • Social Activity: Reduced significantly. Friends visit at home as going out is too painful and tiring. Sees sister weekly.
  • Lifting/Carrying Ability: Can lift less than 5 pounds.

What this filled form sample shows:

  • Detailed descriptions of how pain, stiffness, and fatigue impact daily routines from morning to night.
  • Specific examples of limitations in personal care (dressing, bathing) and household chores (cooking, cleaning).
  • Clear explanation of reduced mobility and transportation abilities, including distances and use of assistive devices.
  • Documentation of cognitive difficulties ('brain fog') affecting memory and concentration.
  • Quantification of abilities, such as how long the person can sit, stand, walk, and how much they can lift.

Form specifications and details:

Form: SSA-3373-BK
Form Name: Function Report - Adult
Agency: Social Security Administration (SSA)
Use Case: Adult claimant with a chronic physical and cognitive medical condition (Severe Rheumatoid Arthritis) applying for disability benefits.
Categories: SSA forms
Created: January 29, 2026 06:37 PM
Completed Form SSA-3373-BK, Function Report - Adult, for a claimant with severe rheumatoid arthritis.