This form contains 197 fields organized into 68 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Abilities Affected - Explanation of Checked Items
Explanation of Abilities Affected	Text	Describe how the person's illnesses, injuries, or conditions affect each item you checked, giving specific limits or examples (for example, how far they can walk, how many pounds they can lift, how tasks are limited, or any other relevant details). Fill only if 'Lifting', 'Squatting', 'Bending', 'Standing', 'Reaching', 'Walking', 'Sitting', 'Kneeling', 'Talking', 'Hearing', 'Stair Climbing', 'Seeing', 'Memory', 'Completing Tasks', 'Concentration', 'Understanding', 'Following Instructions', 'Using Hands', 'Getting Along with Others' is 'Yes' for any fields selection. Depends on: Lifting, Squatting, Bending, Standing, Reaching, Walking, Sitting, Kneeling, Talking, Hearing, Stair Climbing, Seeing, Memory, Completing Tasks, Concentration, Understanding, Following Instructions, Using Hands, Getting Along with Others
Abilities Affected (Checkboxes)
Lifting	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent lifting objects.
Squatting	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent squatting or rising from a squat.
Bending	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent bending at the waist.
Standing	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent standing or standing for periods of time.
Reaching	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent reaching overhead or outward.
Walking	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent walking or affect how far they can walk.
Sitting	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent sitting or sitting for periods of time.
Kneeling	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent kneeling.
Talking	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent speaking or communicating verbally.
Hearing	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent hearing.
Stair Climbing	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent climbing stairs.
Seeing	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent seeing or impair vision.
Memory	Checkbox	Check if the person's illnesses, injuries, or conditions affect memory or the ability to remember things.
Completing Tasks	Checkbox	Check if the person's illnesses, injuries, or conditions interfere with completing tasks or carrying out activities.
Concentration	Checkbox	Check if the person's illnesses, injuries, or conditions affect concentration or the ability to focus.
Understanding	Checkbox	Check if the person's illnesses, injuries, or conditions affect understanding information or others.
Following Instructions	Checkbox	Check if the person's illnesses, injuries, or conditions make it difficult to follow directions or instructions.
Using Hands	Checkbox	Check if the person's illnesses, injuries, or conditions limit or prevent using hands for tasks or manipulation.
Getting Along with Others	Checkbox	Check if the person's illnesses, injuries, or conditions affect getting along with family, friends, neighbors, or others.
Able to Do Before Illness/Injury (Q13)
Q13 — Activities Able to Do Before Illness/Injury	Text	Describe what the disabled person was able to do before his/her illnesses, injuries, or medical conditions that he/she cannot do now, listing specific tasks, activities, or abilities and any relevant details.
Assistive Devices Prescription Details
Which device(s) were prescribed by a doctor	Text	Enter the name(s) of the assistive device(s) that were prescribed by a doctor (or write 'do not know' or 'do not recall' if unsure).
Date or time period prescribed	Text	Enter when the device(s) were prescribed (a specific date or approximate time period), or write 'do not know' or 'do not recall' if you cannot remember.
When person needs to use the aids	Text	Describe when or under what circumstances the person needs to use the assistive device(s) (for example: always, only when walking, only at night, during appointments, etc.).
Assistive Devices Used (Check All That Apply)
Crutches	Checkbox	Check this box if the disabled person uses crutches.
Cane	Checkbox	Check this box if the disabled person uses a cane.
Hearing Aid	Checkbox	Check this box if the disabled person uses a hearing aid.
Walker	Checkbox	Check this box if the disabled person uses a walker.
Brace/Splint	Checkbox	Check this box if the disabled person uses a brace or splint.
Glasses/Contact Lenses	Checkbox	Check this box if the disabled person uses glasses or contact lenses.
Wheelchair	Checkbox	Check this box if the disabled person uses a wheelchair.
Artificial Limb	Checkbox	Check this box if the disabled person uses an artificial limb (prosthesis).
Artificial Voice Box	Checkbox	Check this box if the disabled person uses an artificial voice box.
Other (Explain)	Checkbox	Check this box if the disabled person uses an assistive device not listed above, and describe the device on the provided "Other (Explain)" line.
Other Assistive Device (Explain)	Text	Enter the name and brief explanation of any assistive device not listed above that the disabled person uses; if none or unknown, write "none" or "don't know." Fill only if 'Other (Explain)' is 'Yes'. Depends on: Other (Explain)
Attention Span Duration
Attention span duration	Text	Enter how long the disabled person can pay attention (provide a value and unit, for example "30 minutes", "1 hour", or "a few seconds").
Authority Figures Relationship Description
Authority figures relationship description	Text	Describe how well the disabled person gets along with authority figures (for example, police, bosses, landlords, or teachers); provide a brief narrative such as 'gets along well,' 'has occasional conflicts,' or specific examples.
Cares for Others (Q10)
Cares for Others (Q10) - Yes	Checkbox	Check this box if the person does take care of anyone else (for example spouse, children, grandchildren, parents, friends, or others).
Cares for Others (Q10) - No	Checkbox	Check this box if the person does not take care of anyone else (no responsibility for caring for spouse, children, grandchildren, parents, friends, or others).
Q10 — Cares for Others: For whom and what do they do	Text	Enter the people (relationship to the person, e.g., wife, child, parent, friend, grandchild, other) for whom the person provides care and briefly describe the specific caregiving activities they perform for each (what they do, e.g., prepare meals, bathe, supervise, drive, administer medication). Fill only if 'Cares for Others (Q10) - Yes' is 'Yes'. Depends on: Cares for Others (Q10) - Yes
Cares for Pets/Animals (Q11)
Q11 - Yes (Cares for pets/animals)	Checkbox	Check this box if the person takes care of pets or other animals.
Q11 - No (Does not care for pets/animals)	Checkbox	Check this box if the person does not take care of any pets or other animals.
Q11 — Pet/Animal Care Description	Text	If the person takes care of pets or other animals, describe what they do for them, including the types of animals, the specific care tasks performed (feeding, grooming, walking, cleaning, medical care, etc.), how often they do these tasks, and whether they need help to do them. Fill only if 'Q11 - Yes (Cares for pets/animals)' is 'Yes'. Depends on: Q11 - Yes (Cares for pets/animals)
Changes in Social Activities Since Condition Began
Describe changes in social activities	Text	Describe any ways the person's social activities, friendships, participation in groups or events, or ability to be around others have changed since the illnesses, injuries, or conditions began, including what they do now compared with before.
Daily Activities Description (Q9)
Q9 — Daily activities description	Text	Describe, in your own words, what the disabled person does from the time he/she wakes up until going to bed, listing typical activities and the order or times they occur.
Daytime Telephone Number
Daytime Telephone — Area Code	Text	Enter the 3-digit area code for the daytime telephone number where you can be reached. Fill only if 'None (No Daytime Telephone Number)' is 'No'. Max length: 3 characters
Your Number (Daytime Telephone)	Checkbox	Check this box when you are providing your own daytime telephone number where you can be reached.
Message Number (Daytime Telephone)	Checkbox	Check this box when you are providing a daytime telephone number where messages may be left for you (a message number).
None (No Daytime Telephone Number)	Checkbox	Check this box when there is no daytime telephone number where you can be reached.
Daytime Telephone — Prefix	Text	Enter the first three digits (prefix) of the 7-digit daytime phone number following the area code. Fill only if 'None (No Daytime Telephone Number)' is 'No'. Max length: 3 characters
Daytime Telephone — Line Number	Text	Enter the last four digits (line number) of the 7-digit daytime phone number following the prefix. Fill only if 'None (No Daytime Telephone Number)' is 'No'. Max length: 4 characters
Disabled Person Name
Disabled Person - Full Name	Text	Enter the disabled person's full name as First, Middle, Last (include any suffixes such as Jr. or III if applicable).
Finishes What He/She Starts - Yes/No
Finishes what he/she starts - Yes	Checkbox	Check this box if the disabled person finishes what he or she starts (for example, completes conversations, chores, reading, or watching a movie).
Finishes what he/she starts - No	Checkbox	Check this box if the disabled person does not finish what he or she starts (for example, does not complete conversations, chores, reading, or watching a movie).
Fired or Laid Off Due to Getting Along Issues
Fired or laid off due to getting along issues — Yes	Checkbox	Check this box if the person has been fired or laid off from a job because of problems getting along with other people.
Fired or laid off due to getting along issues — No	Checkbox	Check this box if the person has never been fired or laid off from a job for reasons related to problems getting along with other people.
Explanation of Being Fired or Laid Off	Text	Briefly describe why the person was fired or laid off because of problems getting along with other people, including circumstances, dates, and specific behavior or incidents if known. Fill only if 'Fired or laid off due to getting along issues — Yes' is 'Yes'. Depends on: Fired or laid off due to getting along issues — Yes
Employer Name (if YES)	Text	Enter the name of the employer who fired or laid off the person for getting along issues; if unknown, write 'don't know' or 'unknown'. Fill only if 'Fired or laid off due to getting along issues — Yes' is 'Yes'. Depends on: Fired or laid off due to getting along issues — Yes
Following Spoken Instructions - Description
Following Spoken Instructions (g)	Text	Describe how well the disabled person follows spoken instructions, including any limitations (for example, needs repetition, partial understanding, prompts, or cannot follow complex directions) and examples of typical performance or assistance required.
Following Written Instructions - Description
f. Following Written Instructions — Description	Text	Describe how well the disabled person follows written instructions (for example, a recipe), including specific abilities, limitations, examples, and any factors that affect their performance.
Getting Around - Can Go Out Alone (Yes/No) & Explanation
Can go out alone — Yes	Checkbox	Check this box if the person can go out by themselves (they are able to go out alone).
Can go out alone — No	Checkbox	Check this box if the person cannot go out by themselves (they need assistance or cannot go out alone).
If NO — Why can't go out alone (explanation)	Text	Explain why the person cannot go out alone, listing specific reasons such as mobility or balance problems, need for supervision or assistance, cognitive or medical limitations, or other circumstances that prevent independent outings. Fill only if 'Can go out alone — No' is 'Yes'. Depends on: Can go out alone — No
Getting Around - Does Person Drive (Yes/No) & Explanation
Does the disabled person drive? - Yes	Checkbox	Check this box if the disabled person does drive (i.e., they operate a car themselves).
Does the disabled person drive? - No	Checkbox	Check this box if the disabled person does not drive at all.
Does Person Drive — Explanation	Text	Provide a brief explanation describing whether the person drives and, if they do not, the reasons or limitations that prevent them from driving (for example: medical condition, lack of license, mobility or cognitive issues, or other barriers). Fill only if 'Does the disabled person drive? - No' is 'Yes'. Depends on: Does the disabled person drive? - No
Getting Around - How Often Goes Outside & Why Not
How often goes outside	Text	Enter how often the person goes outside (for example: 'daily', 'several times a week', 'once a month', 'never', or a brief frequency description).
If does not go out, explain why	Text	If the person does not go out at all, provide a brief explanation why (for example: 'homebound due to illness', 'no transportation', or write 'N/A' if this does not apply). Fill only if 'How often goes outside' indicates the person doesn't go out at all. Depends on: How often goes outside
Getting Around - Travel Methods (Check All That Apply)
Walk	Checkbox	Check this box if the person travels by walking when going out.
Drive a car	Checkbox	Check this box if the person drives a car themselves when going out.
Ride in a car	Checkbox	Check this box if the person is a passenger (rides in a car) when going out.
Ride a bicycle	Checkbox	Check this box if the person rides a bicycle when going out.
Use public transportation	Checkbox	Check this box if the person uses public transit (bus, train, subway, etc.) when going out.
Other (Explain)	Checkbox	Check this box if the person uses a travel method not listed here, and describe that method on the line provided.
Other travel method (Explain)	Text	Enter any other method(s) this person uses to travel when going out and briefly explain each one. Fill only if 'Other (Explain)' is 'Yes'. Depends on: Other (Explain)
Handedness (Right/Left)
Right Handed?	Checkbox	Check this box if the disabled person primarily uses their right hand for writing and other tasks (i.e., is right‑hand dominant).
Left Handed?	Checkbox	Check this box if the disabled person primarily uses their left hand for writing and other tasks (i.e., is left‑hand dominant).
Handling Changes in Routine Description
Handling changes in routine — description (k)	Text	Describe how well the disabled person copes with changes in their routine, including typical reactions, examples of recent situations, how often problems occur, and any supports or accommodations that help.
Help Caring for People/Animals (Q12)
12. Yes - Help Caring for People/Animals	Checkbox	Check this box if someone helps this person care for other people or animals (answer is Yes).
12. No - Help Caring for People/Animals	Checkbox	Check this box if no one helps this person care for other people or animals (answer is No).
Q12: Who helps care for other people or animals	Text	Describe who helps the person care for other people or animals and explain what each helper does to provide that care (include relationship to the person and specific tasks performed). Fill only if '12. Yes - Help Caring for People/Animals' is 'Yes'. Depends on: 12. Yes - Help Caring for People/Animals
Help or Reminders Taking Medicine
Help or reminders taking medicine — Yes	Checkbox	Check this box if the person does need help or reminders to take their medicine.
Help or reminders taking medicine — No	Checkbox	Check this box if the person does not need help or reminders to take their medicine.
Help or Reminders for Taking Medicine — Details	Text	Describe what kind of help or reminders the person needs to take their medicine (for example: verbal reminders, someone to give the medicine, help organizing pills, frequency of prompts, or other specific assistance). Fill only if 'Help or reminders taking medicine — Yes' is 'Yes'. Depends on: Help or reminders taking medicine — Yes
Hobbies and Interests - Changes Since Conditions Began
21c. Changes in hobbies and interests since conditions began	Text	Describe any changes in the person’s hobbies, pastimes, or ability to do these activities since the illnesses, injuries, or conditions began, including what changed and how it affected participation.
Hobbies and Interests - Frequency/How Well
Hobbies and Interests — Frequency and How Well	Text	Describe how often the person does each hobby or interest and how well they perform those activities (for example: daily and independently; weekly but needs help; rarely and poorly).
Hobbies and Interests - Hobbies/Interests Description
21a. Hobbies and interests	Text	Describe the person's hobbies and interests (for example, reading, watching TV, sewing, playing sports), listing activities they do or enjoy.
House and Yard Work - Chores, Time, and Help Needed
Chores Performed (House and Yard)	Text	List the household and yard chores the disabled person is able to do, including indoor and outdoor tasks (for example, cleaning, laundry, ironing, mowing, household repairs).
Time and Frequency of Chores	Text	Describe how much time each chore takes and how often the person performs each task (for example, minutes per task, daily, weekly, monthly).
Does he/she need help or encouragement doing these things? - Yes	Checkbox	Check this box if the disabled person needs help or encouragement to do house and yard chores (i.e., they require assistance or prompting to perform household tasks).
Does he/she need help or encouragement doing these things? - No	Checkbox	Check this box if the disabled person does not need any help or encouragement to do house and yard chores (i.e., they can perform household tasks independently).
Help or Encouragement Needed	Text	If assistance or encouragement is required for these chores, describe what specific help is needed and under what circumstances. Fill only if 'Does he/she need help or encouragement doing these things? - Yes' is 'Yes'. Depends on: Does he/she need help or encouragement doing these things? - Yes
House/Yard Work - Explain Why Not
Reason the person does not do house or yard work	Text	Enter a brief explanation of why the disabled person does not perform house or yard work (if you do not know or it does not apply, write "don't know" or "none"). Fill only if 'List household chores, both indoors and outdoors, that the disabled person is able to do' is 'none/does not apply' (i.e., the disabled person doesn't do house or yard work). Depends on: Chores Performed (House and Yard)
Knowledge of Disabled Person (Duration and Time Spent)
How long have you known the disabled person?	Text	Enter how long you have known the disabled person (for example, number of years, months, or a brief date range such as "since 2018").
Time spent with the disabled person and activities	Text	Describe how much time you spend with the disabled person (for example, hours per day or days per week) and list the typical activities you do together.
Meals - Prepare Own Meals and Details
Prepare own meals — Yes	Checkbox	Check this box if the disabled person does prepare his/her own meals.
Prepare own meals — No	Checkbox	Check this box if the disabled person does not prepare his/her own meals.
Kinds of food prepared	Text	Describe what kinds of food the person prepares (for example, sandwiches, frozen dinners, or complete meals with several courses). Fill only if 'Prepare own meals — Yes' is 'Yes'. Depends on: Prepare own meals — Yes
Meal preparation frequency	Text	State how often the person prepares food or meals (for example, daily, twice weekly, or monthly).
Time to prepare meals	Text	Enter how long it typically takes the person to prepare a meal (for example, 30 minutes or 1 hour).
Changes in cooking habits	Text	Describe any changes in the person's cooking habits since the illness, injuries, or conditions began, or write 'none' if there are no changes.
Reason for not preparing meals	Text	If the person does not prepare meals, explain why they cannot or do not prepare meals, including any physical, cognitive, environmental, or other limiting factors. Fill only if 'Prepare own meals — No' is 'Yes'. Depends on: Prepare own meals — No
Medication Use and Side Effects (Yes/No)
Does the disabled person currently take medicines? — Yes	Checkbox	Check this box if the disabled person currently takes any medicines for his/her illnesses, injuries, or conditions.
Does the disabled person currently take medicines? — No	Checkbox	Check this box if the disabled person does not currently take any medicines for his/her illnesses, injuries, or conditions.
Do any of the medicines cause side effects? — Yes	Checkbox	Check this box if any of the medicines the disabled person takes cause side effects. Fill only if 'Does the disabled person currently take medicines? — Yes', 'Does the disabled person currently take medicines? — No' is 'Yes'. Depends on: Does the disabled person currently take medicines? — Yes, Does the disabled person currently take medicines? — No
Do any of the medicines cause side effects? — No	Checkbox	Check this box if none of the medicines the disabled person takes cause side effects. Fill only if 'Does the disabled person currently take medicines? — Yes', 'Does the disabled person currently take medicines? — No' is 'Yes'. Depends on: Does the disabled person currently take medicines? — Yes, Does the disabled person currently take medicines? — No
Medicine Side Effects List - First Row
First Row — Name of Medicine	Text	Enter the name of the medicine the person takes that causes side effects (brand or generic); if unknown or not applicable, write "don't know" or "none". Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
First Row — Side Effects Person Has	Text	Describe the side effects the person experiences from the medicine listed in the same row (briefly list symptoms or reactions); if none or unknown, write "none" or "don't know." Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Medicine Side Effects List - Fourth Row
Fourth Row - Side Effects Person Has	Text	Describe the specific side effect(s) the disabled person experiences from the medicine listed in the fourth row (e.g., nausea, dizziness, rash). Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Fourth Row - Name of Medicine	Text	Enter the name of the medicine (brand or generic) taken by the disabled person that causes side effects in the fourth row of the list. Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Medicine Side Effects List - Second Row
Second Row — Side Effects Person Has	Text	Describe the side effects the disabled person experiences from the medicine listed on the second row; if none or unknown, write 'none' or 'don't know' as applicable. Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Second Row — Name of Medicine	Text	Enter the name of the medicine (on the second row) that the disabled person takes which causes side effects; if unknown write 'don't know' or if none write 'none'. Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Medicine Side Effects List - Third Row
Third Row - Side Effects Person Has	Text	Describe the side effect(s) the disabled person experiences from the medicine entered in the third row (briefly list relevant symptoms or reactions). Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Third Row - Name of Medicine	Text	Enter the name of the medicine (brand or generic) taken by the disabled person that causes side effects for the third row of the list. Fill only if 'Do any of the medicines cause side effects? — Yes' is 'Yes'. Depends on: Do any of the medicines cause side effects? — Yes
Money - Count Change (Yes/No)
Count change — Yes	Checkbox	Check this box if the person is able to count change (make correct change) on their own.
Count change — No	Checkbox	Check this box if the person is not able to count change (cannot make correct change) or needs help to do so.
Money - Explain All 'No' Answers
Money Section — Explain all "No" answers	Text	Enter a clear, detailed explanation for any "No" answers given in the Money section (for example, inability to pay bills, count change, handle a savings account, or use a checkbook/money orders). Fill only if 'Pay bills — No', 'Handle a savings account - No', 'Count change — No', 'Use a checkbook/money orders - No' is 'Yes' (any). Depends on: Pay bills — No, Handle a savings account - No, Count change — No, Use a checkbook/money orders - No
Money - Handle a Savings Account (Yes/No)
Handle a savings account - Yes	Checkbox	Check this box if the person is able to manage and handle a savings account (for example, make deposits, withdrawals, and keep track of the account).
Handle a savings account - No	Checkbox	Check this box if the person is not able to manage or handle a savings account.
Money - Pay Bills (Yes/No)
Pay bills — Yes	Checkbox	Check this box if the person is able to pay their bills (can manage and make bill payments).
Pay bills — No	Checkbox	Check this box if the person is not able to pay their bills (cannot manage or make bill payments).
Money - Use a Checkbook/Money Orders (Yes/No)
Use a checkbook/money orders - Yes	Checkbox	Check this box if the person is able to use a checkbook or money orders (i.e., can record, fill out, and manage checks or money order transactions).
Use a checkbook/money orders - No	Checkbox	Check this box if the person is not able to use a checkbook or money orders and cannot perform those tasks independently.
Money Handling Ability Changed (Yes/No) and Explanation
Has the disabled person's ability to handle money changed? — Yes	Checkbox	Check this box if the disabled person's ability to handle money has changed since the illnesses, injuries, or conditions began.
Has the disabled person's ability to handle money changed? — No	Checkbox	Check this box if the disabled person's ability to handle money has not changed since the illnesses, injuries, or conditions began.
Money-handling change explanation	Text	Describe how the person's ability to handle money has changed since the illnesses, injuries, or conditions began, including specific limitations or difficulties (for example: counting money, paying bills, using a bank, making purchases, or managing finances). Fill only if 'Has the disabled person's ability to handle money changed? — Yes' is 'Yes'. Depends on: Has the disabled person's ability to handle money changed? — Yes
Page 1 Text Field
Page 1 Text Field 1	Text	Enter the short text value requested for this highlighted field on page 1 (type the information exactly as it should appear).
Person Completing Form - Address and Email
Address (Number and Street)	Text	Enter the person completing the form's street address including house/building number, street name and any apartment or unit number.
Email Address (optional)	Text	Enter the person completing the form's email address if available (this field is optional).
City	Text	Enter the city for the person completing the form's mailing address.
State	Text	Enter the state for the mailing address (use the two-letter state abbreviation or full state name).
ZIP Code	Text	Enter the ZIP Code for the mailing address (5-digit ZIP or ZIP+4).
Person Completing Form - Name and Date
Name of person completing form	Text	Enter the full name of the person who is completing and signing this form (print legibly).
Date form completed	Date	Enter the date on which the person completed this form.
Personal Care - No Problem Checkbox (Q15)
Q15 No problem with personal care	Checkbox	Check this box if the person has NO PROBLEM with personal care (their illnesses, injuries, or conditions do not affect their ability to dress, bathe, or perform other personal care activities).
Personal Care Difficulties Details (Q15a)
Q15a - Dress	Text	Explain how the person's illnesses, injuries, or conditions affect their ability to dress, including what they can or cannot do, how much help they need, and any assistive devices used. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Bathe	Text	Describe how the person's illnesses, injuries, or conditions affect their ability to bathe or shower, noting any assistance required, safety concerns, or adaptive equipment used. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Care for hair	Text	Describe how the person's illnesses, injuries, or conditions affect their ability to care for their hair (washing, combing, styling), including any help or tools needed. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Shave	Text	Describe how the person's illnesses, injuries, or conditions affect their ability to shave or perform facial grooming, including assistance, frequency, or adaptive devices required. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Feed self	Text	Describe how the person's illnesses, injuries, or conditions affect their ability to feed themselves, including need for help, special utensils, swallowing issues, or other limitations. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Use the toilet	Text	Describe how the person's illnesses, injuries, or conditions affect their ability to use the toilet, including transferring, continence, assistance needed, or adaptive equipment used. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Q15a - Other personal care	Text	Provide details about any other personal care activities affected by the person's illnesses, injuries, or conditions, specifying the task and how it is limited or what help is required. Fill only if 'Q15 No problem with personal care' is 'No'. Depends on: Q15 No problem with personal care
Personal Needs/Grooming Reminders
Personal Needs/Grooming Reminders — Yes	Checkbox	Check this box if the person needs special reminders or prompts to take care of personal needs and grooming (for example, reminders to bathe, brush teeth, dress, or use the toilet).
Personal Needs/Grooming Reminders — No	Checkbox	Check this box if the person does not need any special reminders or prompts to take care of personal needs and grooming.
Special reminders for personal needs and grooming	Text	Describe any special reminders, prompts, or help the person needs to manage personal care and grooming (for example: bathing, toileting, dressing, hair care, or assistance with hygiene). Fill only if 'Personal Needs/Grooming Reminders — Yes' is 'Yes'. Depends on: Personal Needs/Grooming Reminders — Yes
Problems Getting Along with Others - Explanation
Explanation of Problems Getting Along (1)	Text	Provide a clear explanation of any problems this person has getting along with family, friends, neighbors, or others, including examples of behaviors, situations, frequency, and who is involved. Fill only if 'Problems Getting Along with Others - Yes' is 'Yes'. Depends on: Problems Getting Along with Others - Yes
Problems Getting Along with Others - Yes/No
Problems Getting Along with Others - Yes	Checkbox	Check this box if the person does have problems getting along with family, friends, neighbors, or others.
Problems Getting Along with Others - No	Checkbox	Check this box if the person does not have problems getting along with family, friends, neighbors, or others.
Section E - Remarks
Section E - Remarks	Text	Enter any additional information, explanations, or details you did not include elsewhere on this form; if you have nothing to add, write "none" or "don't know" as appropriate.
Shopping - Describe What Person Shops For
Items the person shops for	Text	Enter a brief description of the types of goods or items the person typically shops for (for example: groceries, clothing, medications, household supplies, etc.).
Shopping - How Often Shops & How Long It Takes
How often shops and typical time per trip	Text	Describe how often the person goes shopping (for example, times per day/week/month) and how long a typical shopping trip takes, including usual duration and any variation or assistance required.
Shopping - How Person Shops (Check All That Apply)
In stores	Checkbox	Check this box if the person does their shopping by going into physical retail stores.
By phone	Checkbox	Check this box if the person places orders or purchases goods by telephone.
By mail	Checkbox	Check this box if the person shops using mail-order (sending orders or payments through the postal service).
By computer	Checkbox	Check this box if the person shops using a computer or online (internet) to order items.
Sleep Affected by Conditions (Q14)
Q14 Sleep Affected by Conditions - Yes	Checkbox	Check this box if the person's illnesses, injuries, or conditions do affect his/her sleep.
Q14 Sleep Affected by Conditions - No	Checkbox	Check this box if the person's illnesses, injuries, or conditions do not affect his/her sleep.
Q14 - How the conditions affect sleep	Text	Describe how the person's illnesses, injuries, or medical conditions affect his or her sleep, including problems with falling asleep, staying asleep, waking frequently, daytime sleepiness, nightmares, pain-related sleep disruption, breathing or movement during sleep, typical timing/duration, and any other sleep-related effects. Fill only if 'Q14 Sleep Affected by Conditions - Yes' is 'Yes'. Depends on: Q14 Sleep Affected by Conditions - Yes
Social Activities - How Spend Time With Others (Methods and Other Explain)
In person	Checkbox	Check this box if the disabled person spends time with others face-to-face (physically together).
On the phone	Checkbox	Check this box if the disabled person spends time with others by telephone calls.
Email	Checkbox	Check this box if the disabled person communicates or spends time with others via email.
Texting	Checkbox	Check this box if the disabled person communicates or spends time with others by text messages (SMS or similar).
Mail	Checkbox	Check this box if the disabled person corresponds or spends time with others through postal mail.
Other (Explain)	Checkbox	Check this box if the disabled person uses a method of spending time with others not listed here, and briefly explain the method on the provided line.
Other Social Activity (Explain)	Text	Enter any other way the disabled person spends time with others that is not listed (for example, community groups, in‑home visitors, rides, or other methods), briefly explaining the activity. Fill only if 'Other (Explain)' is 'Yes'. Depends on: Other (Explain)
Video Chat (for example Skype or Facetime)	Checkbox	Check this box if the disabled person uses video calling (for example Skype, FaceTime, Zoom) to spend time with others.
Social Activities - Need Reminded to Go Places (Yes/No) and Participation Details
Needs to be reminded to go places - Yes	Checkbox	Check this box if the person does need to be reminded or prompted to go to places (for example, needs someone to tell or take them to appointments, events, or regular outings).
Needs to be reminded to go places - No	Checkbox	Check this box if the person does not need reminders or prompting and is able to go to places on their own for appointments, events, or regular outings.
Frequency and Participation Details	Text	Enter how often the person goes to places and a clear description of how much they participate when they go (for example, weekly attendance, how long they stay, activities they join, level of engagement).
Social Activities - Need Someone to Accompany (Yes/No)
Does he/she need someone to accompany him/her? - Yes	Checkbox	Check this box if the disabled person needs someone to accompany him/her when going places.
Does he/she need someone to accompany him/her? - No	Checkbox	Check this box if the disabled person does not need someone to accompany him/her when going places.
Social Activities - Places Goes Regularly
Place Goes Regularly (1)	Text	Enter the name(s) of places the person goes on a regular basis (for example, church, community center, sports events, social groups), listing multiple places separated by commas.
Social Activities - Things Done With Others and Frequency
Activities done with others	Text	Enter a brief description of the kinds of things the person does with other people (for example, visits friends, attends group events, plays cards, talks on the phone, etc.).
Frequency of activities with others	Text	Enter how often the person does the activities listed above (for example, daily, several times a week, weekly, monthly, rarely, or a custom frequency description).
Stress Handling Description
How well does the disabled person handle stress?	Text	Describe how the person copes with stress, including typical reactions, common triggers, frequency and intensity of stress episodes, any difficulties functioning under stress, and whether they need help or accommodations to manage stressful situations.
Third Party (Filler) Information
Third Party Name (Filler)	Text	Enter the full name (first, middle, last) of the person completing this form on behalf of the disabled person.
Third Party Relationship (Filler)	Text	Enter your relationship to the disabled person (for example: spouse, friend, caregiver, attorney). Max length: 20 characters
Third Party Date (Filler)	Date	Enter the date when the person completing the form signed or filled out this section.
Unusual Behavior or Fears
Have you noticed any unusual behavior or fears? - Yes	Checkbox	Check this box if you have observed any unusual behavior or fears in the disabled person.
Have you noticed any unusual behavior or fears? - No	Checkbox	Check this box if you have not observed any unusual behavior or fears in the disabled person.
L. Explanation of unusual behavior or fears	Text	Describe any unusual behavior or fears you have noticed in the disabled person, including specific examples, when they occur, how often they happen, what seems to trigger them, and any actions taken or reactions observed. Fill only if 'Have you noticed any unusual behavior or fears? - Yes' is 'Yes'. Depends on: Have you noticed any unusual behavior or fears? - Yes
Walking Endurance (Distance and Rest Time)
Walking distance before rest	Text	Enter how far the person can walk before needing to stop and rest, including units if known (for example, "2 blocks", "1/4 mile", or "200 feet").
Rest duration before resuming walking	Time	Enter how long the person must rest before they can resume walking (a duration of time).
Where Disabled Person Lives (Residence Type)
House	Checkbox	Check this box if the disabled person currently lives in a house (private residence).
Apartment	Checkbox	Check this box if the disabled person currently lives in an apartment.
Boarding House	Checkbox	Check this box if the disabled person currently lives in a boarding house.
Nursing Home	Checkbox	Check this box if the disabled person currently resides in a nursing home or long-term care facility.
Shelter	Checkbox	Check this box if the disabled person currently lives in a shelter.
Group Home	Checkbox	Check this box if the disabled person currently lives in a group home.
Other (What?)	Checkbox	Check this box if the disabled person lives in a residence type not listed here and write the type in the space provided.
Residence Type - Other (Specify)	Text	Enter the specific type of residence if 'Other' applies for where the disabled person lives (briefly describe the living arrangement, e.g., 'rooming house', 'temporary shelter', 'staying with friend'). Fill only if 'Other (What?)' is 'Yes'.
With Whom Disabled Person Lives
Alone	Checkbox	Check this box if the disabled person lives alone (does not live with family, friends, or other household members).
With Family	Checkbox	Check this box if the disabled person lives with family members (for example, spouse, parents, children, or other relatives).
With Friends	Checkbox	Check this box if the disabled person lives with friends or non-family household members.
Other (describe relationship)	Checkbox	Check this box if the disabled person lives with someone not covered by the other choices, and describe that person's relationship to the disabled person in the space provided.
With Whom Disabled Person Lives - Other (Relationship)	Text	Enter the relationship of the person(s) the disabled person lives with (for example, "daughter", "live-in caregiver", "roommate"); if more than one, list each relationship separated by commas. Fill only if 'Other (describe relationship)' is 'Yes'.
Work Limitation Description
Work Limitation Description	Text	Describe in detail how the disabled person's illnesses, injuries, or conditions limit his or her ability to work, including specific activities or tasks affected, the severity, frequency and duration of limitations, and any aids or accommodations required.

Function Report - Adult - Third Party (Form SSA-3380-BK) Instructions