Form SSA-3373-BK, Function Report - Adult Completed Form Examples and Samples
Explore detailed examples and samples of a completed Form SSA-3373-BK, the Function Report - Adult. Learn how to accurately fill out the form to describe daily limitations for physical or mental conditions and support your Social Security disability claim.
Form SSA-3373-BK Example – Adult with Physical Limitations
How this form was filled:
This example shows how an individual with severe osteoarthritis and degenerative disc disease would complete the Function Report. It details how the condition impacts daily activities like personal care, cooking, household chores, and mobility, providing specific, consistent information about physical limitations.
Information used to fill out the document:
- Applicant Name: Jane Marie Smith
- Condition: Severe Osteoarthritis and Degenerative Disc Disease
- Date of Form Completion: February 5, 2026
- Limitations in Daily Living: Difficulty with personal care (dressing, bathing), preparing complex meals, and most household chores.
- Physical Abilities: Can lift less than 5 lbs; walk for 5-10 minutes with a cane; sit for 20-30 minutes before needing to shift positions.
- Hobbies & Social Life: Gave up gardening and hiking; now reads and watches TV. Social outings are infrequent due to pain and fatigue.
- Transportation: Drives short distances on good days; avoids night driving and requires assistance with shopping.
- Medications & Side Effects: Takes Ibuprofen, Meloxicam, and Tramadol; side effects include drowsiness and fatigue.
- Assistance Required: Husband assists with cooking, shopping, and heavy household chores.
What this filled form sample shows:
- Detailed descriptions of how daily activities (personal care, meals, housework) are impacted by the condition.
- Specific, measurable examples of physical limitations (e.g., 'can lift less than 5 lbs', 'walk for 5-10 minutes').
- Clear connection between the reported medical condition and the functional restrictions.
- Inclusion of information on medication side effects like drowsiness that further limit daily function.
- Consistency in reporting limitations across different sections of the form.
Form specifications and details:
| Use Case: | Adult applicant for SSDI/SSI with physical impairments (arthritis and degenerative disc disease). |
| Form Name: | Form SSA-3373-BK, Function Report - Adult |
| Agency: | Social Security Administration (SSA) |
| Purpose: | To collect information from an applicant about their disability and how it affects their ability to function in daily life. |
Created: January 29, 2026 06:27 PM
