This form contains 197 fields organized into 71 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Affected Abilities (20a) - Check All That Apply
20a Lifting	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to lift objects.
20a Squatting	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to squat.
20a Bending	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to bend at the waist or body.
20a Standing	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to stand.
20a Reaching	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to reach with your arms or hands.
20a Walking	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to walk or ambulate.
20a Sitting	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to sit for periods of time.
20a Kneeling	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to kneel.
20a Talking	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to speak or talk.
20a Hearing	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to hear.
20a Stair Climbing	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to climb stairs.
20a Seeing	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your vision or ability to see.
20a Memory	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your memory.
20a Completing Tasks	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to complete tasks.
20a Concentration	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to concentrate or focus.
20a Understanding	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to understand information or instructions.
20a Following Instructions	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to follow instructions.
20a Using Hands	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to use your hands for tasks.
20a Getting Along With Others	Checkbox	Check this box if your illnesses, injuries, or conditions limit or affect your ability to get along with other people.
Assistive Devices Used (Check All That Apply) and Other Explanation
Crutches	Checkbox	Check this box if you use crutches to assist with walking.
Cane	Checkbox	Check this box if you use a cane to assist with walking or balance.
Hearing Aid	Checkbox	Check this box if you use a hearing aid to improve your hearing.
Walker	Checkbox	Check this box if you use a walker to assist with walking and balance.
Brace/Splint	Checkbox	Check this box if you use a brace or splint to support or immobilize a body part.
Glasses/Contact Lenses	Checkbox	Check this box if you use glasses or contact lenses to correct your vision.
Wheelchair	Checkbox	Check this box if you use a wheelchair for mobility.
Artificial Limb	Checkbox	Check this box if you use an artificial limb (prosthesis).
Artificial Voice Box	Checkbox	Check this box if you use an artificial voice box or other device to assist with speaking.
Other (Explain)	Checkbox	Check this box if you use an assistive device not listed here and write the explanation on the line provided.
Other assistive device (explain)	Text	Enter a brief description of any assistive device you use that is not listed in the checkboxes (for example, specific equipment or device name). Fill only if 'Other (Explain)' is selected. Depends on: Other (Explain)
Daytime Telephone Number (Area Code, Number, and Type)
Area Code (Daytime Telephone)	Text	Enter the 3-digit area code for your daytime telephone number, e.g., the first three digits of the number where you can be reached.
Phone Number (Daytime Telephone)	Text	Enter the local portion of your daytime telephone number (the phone number excluding the area code) where you can be reached or where a message can be left.
Your Number	Checkbox	Check this box when the daytime telephone number you entered is your primary number where you can be reached.
Message Number	Checkbox	Check this box when the daytime telephone number you entered is one where messages can be left but may not reach you directly.
None	Checkbox	Check this box when you do not have a daytime telephone number where you can be reached.
Devices Prescribed by a Doctor
Prescribed device(s)	Text	Enter the device or devices from the list above that were prescribed by a doctor, listing each item (and any relevant details such as side, model, or other identifying information) separated by commas. Fill only if 'Crutches', 'Cane', 'Hearing Aid', 'Walker', 'Brace/Splint', 'Glasses/Contact Lenses', 'Wheelchair', 'Artificial Limb', 'Artificial Voice Box', 'Other (Explain)' any are selected. Depends on: Crutches, Cane, Hearing Aid, Walker, Brace/Splint, Glasses/Contact Lenses, Wheelchair, Artificial Limb, Artificial Voice Box, Other (Explain)
Disabled Person Identification (Name and SSN)
Name of Disabled Person	Text	Enter the disabled person's full name in the order First, Middle initial, Last as it should appear on official records.
Social Security Number	Text	Enter the disabled person's nine-digit Social Security number without spaces or dashes.
Explain How Conditions Affect Checked Abilities (20a)
20a: How your conditions affect checked abilities	Text	Describe how your illnesses, injuries, or conditions affect each ability you checked (for example, state specific limits such as how many pounds you can lift, how far you can walk, how long you can stand or sit, or any other restrictions or symptoms). Fill only if '20a Lifting', '20a Squatting', '20a Bending', '20a Standing', '20a Reaching', '20a Walking', '20a Sitting', '20a Kneeling', '20a Talking', '20a Hearing', '20a Stair Climbing', '20a Seeing', '20a Memory', '20a Completing Tasks', '20a Concentration', '20a Understanding', '20a Following Instructions', '20a Using Hands', '20a Getting Along With Others' is checked (any). Depends on: 20a Lifting, 20a Squatting, 20a Bending, 20a Standing, 20a Reaching, 20a Walking, 20a Sitting, 20a Kneeling, 20a Talking, 20a Hearing, 20a Stair Climbing, 20a Seeing, 20a Memory, 20a Completing Tasks, 20a Concentration, 20a Understanding, 20a Following Instructions, 20a Using Hands, 20a Getting Along With Others
Finish What You Start (20e)
20e Finish What You Start — Yes	Checkbox	Check this box if you generally finish what you start (for example, completing a conversation, chores, reading, or watching a movie).
20e Finish What You Start — No	Checkbox	Check this box if you do not generally finish what you start (for example, you often leave conversations, chores, reading, or movies unfinished).
Fired/Laid Off Due to Problems Getting Along With Others (20i)
20i - Yes (Fired/Laid Off Due to Problems Getting Along With Others)	Checkbox	Check this box if you have ever been fired or laid off from a job because of problems getting along with other people.
20i - No (Fired/Laid Off Due to Problems Getting Along With Others)	Checkbox	Check this box if you have never been fired or laid off from a job for problems getting along with other people.
20i — Explanation of Firing/Layoff	Text	Provide a clear, concise description of the circumstances when you were fired or laid off due to problems getting along with others, including dates, reasons, involved people, and any relevant details. Fill only if '20i - Yes (Fired/Laid Off Due to Problems Getting Along With Others)' is 'Yes'. Depends on: 20i - Yes (Fired/Laid Off Due to Problems Getting Along With Others)
20i — Employer Name	Text	Enter the name of the employer who fired or laid you off for problems getting along with other people. Fill only if '20i - Yes (Fired/Laid Off Due to Problems Getting Along With Others)' is 'Yes'. Depends on: 20i - Yes (Fired/Laid Off Due to Problems Getting Along With Others)
Follow Spoken Instructions (20g)
20g. Follow Spoken Instructions	Text	Describe how well you are able to follow spoken instructions (for example, whether you can follow one- or multi-step verbal directions, need repetition or clarification, or have difficulty completing tasks after hearing them).
Follow Written Instructions (20f)
20f. How well do you follow written instructions?	Text	Describe how well you can follow written instructions (for example, a recipe), including any limitations, examples, how often you can complete them, and whether you need help to do so.
Get Along With Authority Figures (20h)
20h. Get Along With Authority Figures	Text	Describe how well you get along with authority figures (for example, police, bosses, landlords, or teachers), including any typical difficulties, examples, frequency, and how these interactions affect your daily life or ability to work.
Getting Around - Can You Go Out Alone (Yes/No and Explain If No)
Can you go out alone — Yes	Checkbox	Check this box if, when you go out, you are able to go out by yourself without needing assistance or supervision.
Can you go out alone — No	Checkbox	Check this box if, when you go out, you are not able to go out alone (you need assistance, supervision, or are otherwise unable to go out by yourself); if checked, explain why in the space provided.
If No, Explain Why You Can't Go Out Alone	Text	Describe why you cannot go out alone, including any physical, mental, safety, mobility, vision, transportation, or supervision needs and examples of situations when you need help. Fill only if 'Can you go out alone — No' is 'Yes'. Depends on: Can you go out alone — No
Getting Around - Do You Drive (Yes/No and Explain If No)
Do you drive? - Yes	Checkbox	Check this box if you currently drive a vehicle.
Do you drive? - No	Checkbox	Check this box if you do not drive a vehicle (and then explain why on the lines provided).
Driving explanation (If you don't drive)	Text	Write a brief explanation of why you do not drive, including any medical, physical, legal, or other reasons or limitations; if you do drive, leave this blank or enter N/A. Fill only if 'Do you drive? - No' is 'Yes'. Depends on: Do you drive? - No
Getting Around - How Often Go Outside
How often do you go outside?	Text	Enter how often you go outside using a short phrase (for example, “daily,” “several times a week,” “rarely,” or “never”).
If you don't go out at all, explain why not	Text	If you do not go outside, provide a brief explanation of the reasons or barriers that keep you from going out; otherwise leave this blank or note that it does not apply. Fill only if 'How often do you go outside?' indicates you don't go out at all. Depends on: How often do you go outside?
Getting Around - Travel Methods (Check All That Apply)
Walk	Checkbox	Check this box if you travel by walking when you go out.
Drive a car	Checkbox	Check this box if you drive a car yourself when you go out.
Ride in a car	Checkbox	Check this box if you are a passenger (ride) in a car when you go out.
Ride a bicycle	Checkbox	Check this box if you ride a bicycle when you go out.
Use public transportation	Checkbox	Check this box if you use buses, trains, subways, or other public transportation when you go out.
Other (Explain)	Checkbox	Check this box if you use a travel method not listed and write the method on the line provided.
Other travel method (explain)	Text	Enter any other way you travel when going out that is not listed (for example, taxi, rideshare, paratransit, mobility scooter), briefly explaining the method. Fill only if 'Other (Explain)' is 'Yes'. Depends on: Other (Explain)
Handedness
Right Handed?	Checkbox	Check this box if you are primarily right-handed (you primarily use your right hand for tasks such as writing, eating, and handling objects).
Left Handed?	Checkbox	Check this box if you are primarily left-handed (you primarily use your left hand for tasks such as writing, eating, and handling objects).
Handling Changes in Routine Description
How well do you handle changes in routine?	Text	Describe how you handle changes to your daily routine, including how well you adapt, any difficulties you experience, examples of recent changes, and the effect those changes have on your functioning.
Header Field
Header short text / code	Text	Enter the short text, code, or brief note to appear in the form header near the title (a small string such as an internal tracking code or qualifier).
Help or Reminders Taking Medicine (Yes/No and If Yes, Details)
Help or reminders taking medicine — Yes	Checkbox	Check this box if you do need help or reminders to take your medicine; if checked, also provide details on the lines below about what kind of help you need. Depends on: 12. No Problem with Personal Care
Help or reminders taking medicine — No	Checkbox	Check this box if you do not need any help or reminders to take your medicine. Depends on: 12. No Problem with Personal Care
Help/Reminders for Taking Medicine — Details	Text	Describe the kind of help or reminders you need to take your medicine, including who provides the help, how often or when reminders are given, what tasks they perform (for example, giving doses, setting alarms, preparing pills), and any special instructions. 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
Changes in hobbies and interests since conditions began	Text	Describe any changes to your hobbies and interests since your illnesses, injuries, or conditions began, including what activities changed, how they changed (for example, reduced frequency, difficulty, or inability to perform), and any limitations or examples.
Hobbies and Interests - Frequency and Ability
Frequency and ability to perform hobbies	Text	Describe how often you do each hobby or interest and how well you can do them (for example, daily/weekly, with difficulty, independently), listing frequency and level of ability for each activity.
Hobbies and Interests - List Hobbies and Interests
Hobbies and Interests (1)	Text	Enter your hobbies and interests (for example: reading, watching TV, sewing, playing sports), listing each activity separated by commas.
House and Yard Work - Chores You Can Do and Time/Frequency
Household chores you can do	Text	Enter the household chores you are able to do, both indoors and outdoors (for example: cleaning, laundry, repairs, ironing, mowing); list each chore or activity in this box.
Time and frequency for listed chores	Text	Describe how much time each listed chore takes and how often you perform each one (for example: 30 minutes — daily; 2 hours — weekly).
House and Yard Work - If You Don't Do It, Explain Why
If you don't do house or yard work, explain why not	Text	Briefly explain why you do not do house or yard work, listing health issues, physical limitations, lack of ability or opportunity, need for assistance, or any other reasons that prevent you from doing these tasks.
House and Yard Work - Need Help/Encouragement (Yes/No and If Yes, What Help)
House and Yard Work - Need help or encouragement: Yes	Checkbox	Check this box if you do need help or encouragement doing household or yard chores (for example, cleaning, laundry, repairs, mowing).
House and Yard Work - Need help or encouragement: No	Checkbox	Check this box if you do not need help or encouragement doing household or yard chores.
House and Yard Work — Help/Encouragement Needed	Text	If you answered Yes to needing help or encouragement with house and yard work, describe the specific kinds of assistance, reminders, or encouragement you need to perform those chores (for example, physical help, supervision, prompts, or equipment). Fill only if 'House and Yard Work - Need help or encouragement: Yes' is 'Yes'. Depends on: House and Yard Work - Need help or encouragement: Yes
How Long Can You Pay Attention (20d)
20d. How long can you pay attention	Text	Enter how long you can pay attention before needing to stop or take a break, including units (for example, "30 minutes" or "2 hours").
Meals - If Not Preparing Meals, Explain Why
Reason you do not prepare meals	Text	Enter a clear explanation of why you cannot or do not prepare your own meals, including any physical, cognitive, safety, equipment, or environmental reasons and how your illness, injuries, or conditions affect meal preparation. Fill only if 'Do you prepare your own meals? — No' is 'Yes'. Depends on: Do you prepare your own meals? — No
Meals - Prepare Own Meals (Yes/No and Preparation Details)
Do you prepare your own meals? — Yes	Checkbox	Check this box if you prepare your own meals (you personally make or assemble the food you eat).
Do you prepare your own meals? — No	Checkbox	Check this box if you do not prepare your own meals (someone else prepares your meals or you rely on prepared/ delivered meals).
Types of Food You Prepare	Text	Describe the kinds of food or meals you prepare (for example, sandwiches, frozen dinners, full multi-course meals), including typical dishes or meal components. Fill only if 'Do you prepare your own meals? — Yes' is 'Yes'. Depends on: Do you prepare your own meals? — Yes
How Often You Prepare Meals	Text	State how often you prepare food or meals using words (for example, daily, several times a week, weekly, or monthly).
Typical Time to Prepare a Meal	Text	Enter how long it usually takes you to prepare a meal, including units (for example, '30 minutes' or '1–2 hours').
Changes in Cooking Habits Since Illness	Text	Describe any changes in your cooking or meal preparation since your illness, injury, or condition began, including limitations, new difficulties, or adaptations.
Medicines and Side Effects - Fifth Entry
Fifth medicine name	Text	Enter the name of the fifth medicine you take that causes side effects. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Fifth medicine side effects	Text	Describe the side effects you experience from the fifth medicine listed. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Medicines and Side Effects - First Entry
First medicine - Name of medicine	Text	Enter the name of the first medicine you take that causes side effects (brand or generic name). Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
First medicine - Side effects you have	Text	Describe the side effects you experience from the first medicine, listing symptoms or reactions caused by this medication. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Medicines and Side Effects - Fourth Entry
Fourth medicine name	Text	Enter the name of the fourth medicine (the medication that causes side effects) as written on the label or prescription. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Fourth medicine side effects	Text	Describe the side effects you experience from the fourth medicine, listing the symptoms or reactions caused by this medication. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Medicines and Side Effects - Second Entry
2nd Medicine Name	Text	Enter the name of the medicine (the second medicine listed) that causes side effects. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
2nd Medicine Side Effects	Text	Describe the side effects you experience from the medicine entered in the corresponding name field. Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Medicines and Side Effects - Third Entry
Third medicine name	Text	Enter the name of the third medicine you take that causes side effects (brand or generic name). Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Third medicine side effects	Text	Describe the side effects you experience from the third medicine (list symptoms or reactions caused by this medicine). Fill only if 'Q22 - Yes', 'Do any of your medicines cause side effects? — Yes' is 'Yes' for all fields. Depends on: Q22 - Yes, Do any of your medicines cause side effects? — Yes
Money - Ability to Handle Money Changed (Yes/No and Explain If Yes)
Ability to handle money changed - Yes	Checkbox	Check this box if your ability to handle money has changed since your illnesses, injuries, or conditions began (and then explain how it has changed in the space provided).
Ability to handle money changed - No	Checkbox	Check this box if your ability to handle money has not changed since your illnesses, injuries, or conditions began.
Ability to handle money — explanation	Text	If you answered "Yes" that your ability to handle money has changed, describe how it has changed since your illnesses, injuries, or conditions began, including specific difficulties, examples (paying bills, counting change, managing a savings account, using a checkbook), and any help you need; if you answered "No," you may leave this blank. Fill only if 'Ability to handle money changed - Yes' is 'Yes'. Depends on: Ability to handle money changed - Yes
Money - Ability to Manage Money (Yes/No Responses)
Pay bills — Yes	Checkbox	Check this box if the person is able to pay their bills.
Pay bills — No	Checkbox	Check this box if the person is not able to pay their bills.
Count change — Yes	Checkbox	Check this box if the person is able to count change correctly.
Count change — No	Checkbox	Check this box if the person is not able to count change correctly.
Handle a savings account — Yes	Checkbox	Check this box if the person is able to handle a savings account.
Handle a savings account — No	Checkbox	Check this box if the person is not able to handle a savings account.
Use a checkbook/money orders — Yes	Checkbox	Check this box if the person is able to use a checkbook or money orders.
Use a checkbook/money orders — No	Checkbox	Check this box if the person is not able to use a checkbook or money orders.
Money - Explain All 'No' Answers
Money — Explain all "No" answers	Text	Enter a clear explanation for each item in section 17a that you answered "No" to, specifying which ability (for example, paying bills, counting change, handling a savings account, or using a checkbook/money orders) and briefly describing why you cannot perform it. Fill only if 'Pay bills — No', 'Count change — No', 'Handle a savings account — No', 'Use a checkbook/money orders — No' is 'Yes' for any. Depends on: Pay bills — No, Count change — No, Handle a savings account — No, Use a checkbook/money orders — No
Paperwork Reduction Act Statement - Margin Field
Margin Note 1 - Paperwork Reduction Act Statement	Text	Enter the margin note, code, or short comment that appears in the right margin next to the Paperwork Reduction Act Statement on this page.
Person Completing Form - Contact Information
Name of person completing form	Text	Enter the full name of the person who completed and is signing this form.
Date completed	Date	Enter the date when the person completed this form.
Email address (optional)	Text	Provide the email address of the person completing the form, or leave blank if none.
Address (Number and Street)	Text	Enter the street number and street name of the person’s mailing address.
City	Text	Enter the city for the person’s mailing address.
State	Text	Enter the state for the person’s mailing address.
ZIP Code	Text	Enter the postal ZIP code for the person’s mailing address.
Personal Needs & Grooming Reminders (Yes/No and If Yes, Details)
Need special reminders for personal needs and grooming — Yes	Checkbox	Check this box if you do need any special reminders or help to take care of personal needs and grooming. Depends on: 12. No Problem with Personal Care
Need special reminders for personal needs and grooming — No	Checkbox	Check this box if you do not need any special reminders or help to take care of personal needs and grooming. Depends on: 12. No Problem with Personal Care
b. Personal Needs & Grooming – Details	Text	If you answered Yes to needing reminders for personal needs and grooming, describe the specific type(s) of help or reminders required (for example: bathing prompts, toileting reminders, assistance with dressing, hair care, shaving, nail care, frequency, and any special instructions). Fill only if 'Need special reminders for personal needs and grooming — Yes' is 'Yes'. Depends on: Need special reminders for personal needs and grooming — Yes
Privacy Act Statements - Header Field
Privacy Act Statements Header Text	Text	Enter the short header text that appears at the top of the Privacy Act Statements section (the section title or heading shown on the form).
Q10 Activities You Could Do Before But Can't Now
Q10 — Activities you could do before but can't now	Text	Briefly list the activities, tasks, or abilities you were able to do before your illnesses, injuries, or conditions that you can no longer do now.
Q11 Sleep Affected (Yes/No and How)
Q11 - Yes	Checkbox	Check this box if your illnesses, injuries, or conditions do affect your sleep.
Q11 - No	Checkbox	Check this box if your illnesses, injuries, or conditions do not affect your sleep.
Q11 — Sleep Impact (If Yes, How)	Text	Describe how your illnesses, injuries, or conditions affect your sleep, including specific problems (for example trouble falling asleep, staying asleep, frequent waking, nightmares, needing naps, pain-related awakenings), their frequency, and how long they typically last. Fill only if 'Q11 - Yes' is 'Yes'. Depends on: Q11 - Yes
Q12 Personal Care (No Problem Checkbox and Explanations)
Q12 Dress	Text	Describe how your illnesses, injuries, or conditions affect your ability to dress yourself, including any assistance required, devices used, or specific limitations. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Bathe	Text	Explain how your illnesses, injuries, or conditions affect your ability to bathe or shower, including any help needed, aids used, or restrictions on the activity. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Care for hair	Text	Describe how your illnesses, injuries, or conditions affect your ability to care for your hair (wash, comb, style), noting any assistance, tools, or limitations. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Shave	Text	Explain how your illnesses, injuries, or conditions affect your ability to shave or groom facial hair, including any help, devices, or limitations. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Feed self	Text	Describe how your illnesses, injuries, or conditions affect your ability to feed yourself, including difficulties, need for assistance, or adaptive equipment used. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Use the toilet	Text	Explain how your illnesses, injuries, or conditions affect your ability to use the toilet and manage related hygiene and clothing, including any assistance or devices needed. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
Q12 Other personal care	Text	Describe any other personal care activities affected by your illnesses, injuries, or conditions and explain how they limit you or require assistance or equipment. Fill only if '12. No Problem with Personal Care' is 'No'. Depends on: 12. No Problem with Personal Care
12. No Problem with Personal Care	Checkbox	Check this box if you have no problems with personal care (dressing, bathing, toileting, grooming, etc.) due to your illnesses, injuries, or conditions.
Q22 Medicine Side Effects (Yes/No)
Do any of your medicines cause side effects? — Yes	Checkbox	Check this box if you answered YES to taking medicines for your conditions and at least one of those medicines causes side effects. Fill only if 'Q22 - Yes' is 'Yes'. Depends on: Q22 - Yes
Do any of your medicines cause side effects? — No	Checkbox	Check this box if you answered YES to taking medicines for your conditions and none of your medicines cause side effects. Fill only if 'Q22 - Yes' is 'Yes'. Depends on: Q22 - Yes
Q22 Medicines Currently Taken (Yes/No)
Q22 - Yes	Checkbox	Check this box if you currently take any medicines for your illnesses, injuries, or conditions.
Q22 - No	Checkbox	Check this box if you do not currently take any medicines for your illnesses, injuries, or conditions.
Q6 Daily Activities Description
Q6: Daily Activities Description	Text	Write a detailed narrative of everything you do from the time you wake up until you go to bed, including routines, tasks, times, and any assistance you need.
Q7 Care for Others (Yes/No and Details)
Q7. Yes	Checkbox	Check this box if you do take care of anyone else (for example a spouse, children, grandchildren, parents, friends, or others).
Q7. No	Checkbox	Check this box if you do not take care of anyone else.
Q7 — Care Recipient(s) and Activities	Text	If you answered Yes to Q7, enter who you care for (name and relationship, e.g., spouse, child, parent) and describe specifically what you do for them (for example: bathing, feeding, transportation, medication reminders, financial management, supervision). Fill only if 'Q7. Yes' is 'Yes'. Depends on: Q7. Yes
Q8 Care for Pets/Animals (Yes/No and Details)
Q8 Yes - Take care of pets or other animals	Checkbox	Check this box if you do take care of pets or other animals.
Q8 No - Take care of pets or other animals	Checkbox	Check this box if you do not take care of any pets or other animals.
Q8 — Care for Pets/Animals (Details)	Text	Enter a clear description of the care you provide for pets or other animals (for example, feeding, grooming, walking, veterinary visits); if you do not care for any pets, write 'None'. Fill only if 'Q8 Yes - Take care of pets or other animals' is 'Yes'. Depends on: Q8 Yes - Take care of pets or other animals
Q9 Help Caring for Others/Animals (Yes/No and Details)
Q9 (First) Yes - Someone helps you care for other people or animals	Checkbox	Check this box if someone does help you care for other people or animals.
Q9 (First) No - No one helps you care for other people or animals	Checkbox	Check this box if no one helps you care for other people or animals.
Q9 — Who helps and what they do	Text	Enter the names or relationship of any people who help you care for others or animals and describe specifically what each person does to help (tasks, frequency, and any limitations). Fill only if 'Q9 (First) Yes - Someone helps you care for other people or animals' is 'Yes'. Depends on: Q9 (First) Yes - Someone helps you care for other people or animals
Rest Time Needed Before Resuming Walking (20c)
20c - Rest time before resuming walking	Text	Enter how long you need to rest before you can resume walking (for example, '5 minutes', '15–20 minutes', or '30 seconds').
Section E - Remarks
Section E - Remarks	Text	Enter any additional information, explanations, or notes you did not show in earlier parts of the form that are relevant to your application.
Shopping - Describe What You Shop For
Describe what you shop for	Text	Enter a brief list or description of the items, goods, or services you typically shop for (for example: groceries, clothing, medications, household supplies, etc.).
Shopping - How Often You Shop and How Long It Takes
Shopping frequency and duration	Text	Enter how often you go shopping (for example: daily, weekly, monthly) and the typical length of time each shopping trip takes (for example: 30 minutes, 2 hours).
Shopping - How You Shop (Check All That Apply)
In stores	Checkbox	Check this box if you do any shopping in person at physical retail stores.
By phone	Checkbox	Check this box if you place orders or make purchases by telephone.
By mail	Checkbox	Check this box if you order goods or shop using mail-order or catalog/mail services.
By computer	Checkbox	Check this box if you shop online using a computer (place orders over the internet).
Social Activities - Changes Since Conditions Began
19.e Changes in social activities since conditions began	Text	Describe any changes in your social activities, interactions, or ability to participate in social events since your illnesses, injuries, or conditions began, including examples and how those activities differ now.
Social Activities - How Often You Do These Things
How often do you do these things?	Text	Enter how frequently you take part in the social activities described above (for example, daily, several times a week, once a month, or a specific number of times).
Social Activities - How Often You Go and Participation Level
How often you go and participation level	Text	Describe how often you go to the places you listed and how much you take part in the activities there (for example, daily/weekly/monthly and whether you participate fully, partially, or only observe).
Social Activities - How You Spend Time With Others (Methods & Other Explain)
In person	Checkbox	Check this box if you spend time with others face-to-face (in person).
On the phone	Checkbox	Check this box if you spend time with others by talking on the phone.
Email	Checkbox	Check this box if you communicate or spend time with others by email.
Texting	Checkbox	Check this box if you communicate or spend time with others via text messages.
Mail	Checkbox	Check this box if you communicate or keep in touch with others through postal mail.
Other (Explain)	Checkbox	Check this box only if you use a different method not listed, and write an explanation on the line provided.
Other social activity method (Explain)	Text	Enter a brief explanation of any other way you spend time with others that is not listed (for example, specify the method or platform and how you use it). Fill only if 'Other (Explain)' is 'Yes'. Depends on: Other (Explain)
Video Chat (for example Skype or Facetime)	Checkbox	Check this box if you use video chat services (for example Skype or FaceTime) to spend time with others.
Social Activities - Kinds of Things You Do With Others
Kinds of Things You Do With Others	Text	Describe the activities and things you do with other people (for example, visit, shop, attend events, play games, volunteer), providing enough detail for each type of activity.
Social Activities - Need Reminders to Go Places (Yes/No)
Need reminders to go places — Yes	Checkbox	Check this box if the person does need to be reminded to go to places (for example, needs prompts or reminders to attend appointments, events, or regular outings).
Need reminders to go places — No	Checkbox	Check this box if the person does not need to be reminded and is able to go to places without prompts or reminders.
Social Activities - Need Someone to Accompany You (Yes/No & Explain)
Do you need someone to accompany you? - Yes	Checkbox	Check this box if you need someone to accompany you when you go places.
Do you need someone to accompany you? - No	Checkbox	Check this box if you do not need someone to accompany you when you go places.
Need Someone to Accompany You — Explain	Text	Describe why you need someone to accompany you when you go out, including what help they provide, when and how often you need accompaniment, and any limitations or conditions that make accompaniment necessary. Fill only if 'Do you need someone to accompany you? - Yes' is 'Yes'. Depends on: Do you need someone to accompany you? - Yes
Social Activities - Places You Go Regularly
Place 1 - Regular place you go	Text	Enter the name and brief identifying details (for example, church, community center, or sports venue and its location) of a place you go on a regular basis.
Social Activities - Problems Getting Along With Others (Yes/No & Explain)
Problems Getting Along With Others - Yes	Checkbox	Check this box if you have any problems getting along with family, friends, neighbors, or other people (and then explain below).
Problems Getting Along With Others - No	Checkbox	Check this box if you do not have any problems getting along with family, friends, neighbors, or other people.
Problems Getting Along With Others — Explanation	Text	Describe any problems you have getting along with family, friends, neighbors, or others, including what the problems are, who is involved, how often they occur, and any effects on your relationships or activities. Fill only if 'Problems Getting Along With Others - Yes' is 'Yes'. Depends on: Problems Getting Along With Others - Yes
Stress Handling Description
j. How well do you handle stress?	Text	Describe how well you handle stress, providing concrete examples of typical reactions, coping strategies, and any limitations or triggers that affect your ability to manage stress.
Unusual Behavior or Fears (Yes/No and Explain)
Have you noticed any unusual behavior or fears? - Yes	Checkbox	Check this box if you have noticed any unusual behavior or fears and will provide an explanation in the space provided.
Have you noticed any unusual behavior or fears? - No	Checkbox	Check this box if you have not noticed any unusual behavior or fears.
Unusual Behavior or Fears — Explanation	Text	Provide a clear description of any unusual behaviors or fears (if you answered Yes), including examples, when they occur, how often they happen, possible triggers, when they began, and how they affect daily activities. 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 Distance Before Rest (20c)
20c. Walking distance before rest	Text	Enter how far you can walk before needing to stop and rest, giving an approximate distance and units (for example, '200 feet', '2 blocks', or '0.5 miles').
When Aids Are Needed
When do you need to use these aids	Text	Describe when, how often, and under what circumstances you need to use your assistive devices (for example: always, only when walking outdoors, at night, for long distances, during dressing), including any specific situations or limitations. Fill only if 'Crutches', 'Cane', 'Hearing Aid', 'Walker', 'Brace/Splint', 'Glasses/Contact Lenses', 'Wheelchair', 'Artificial Limb', 'Artificial Voice Box', 'Other (Explain)' any are selected. Depends on: Crutches, Cane, Hearing Aid, Walker, Brace/Splint, Glasses/Contact Lenses, Wheelchair, Artificial Limb, Artificial Voice Box, Other (Explain)
When Prescribed
When was it prescribed?	Date	Enter the date the assistive device or aid was prescribed by a doctor. Fill only if 'Crutches', 'Cane', 'Hearing Aid', 'Walker', 'Brace/Splint', 'Glasses/Contact Lenses', 'Wheelchair', 'Artificial Limb', 'Artificial Voice Box', 'Other (Explain)' any are selected. Depends on: Crutches, Cane, Hearing Aid, Walker, Brace/Splint, Glasses/Contact Lenses, Wheelchair, Artificial Limb, Artificial Voice Box, Other (Explain)
Where Do You Live (Housing Type)
House	Checkbox	Check this box if you currently live in a house.
Apartment	Checkbox	Check this box if you currently live in an apartment.
Boarding House	Checkbox	Check this box if you currently live in a boarding house or rooming house.
Nursing Home	Checkbox	Check this box if you currently live in a nursing home.
Shelter	Checkbox	Check this box if you currently live in a shelter.
Group Home	Checkbox	Check this box if you currently live in a group home.
Other (What?)	Checkbox	Check this box if your housing type is not listed, and write what it is on the line provided.
Where Do You Live - Other (Specify)	Text	If your housing does not fit the listed options, enter the name or brief description of your housing type (for example: 'Rooming house', 'Mobile home', 'Live with employer', etc.). Fill only if 'Other (What?)' is 'Yes'. Depends on: Other (What?)
With Whom Do You Live (Household Situation)
Alone	Checkbox	Check this box if you live by yourself and do not share your household with anyone else.
With Family	Checkbox	Check this box if you live with family members (for example, a spouse, parent, children, or other relatives).
With Friends	Checkbox	Check this box if you live with friends or roommates who are not family members.
Other (Describe relationship)	Checkbox	Check this box if you live with someone not listed above, and describe their relationship to you on the line provided.
Household Member Relationship (Other)	Text	Enter a brief description of the relationship of the person(s) you live with when you selected 'Other' (for example, 'caregiver - neighbor', 'live-in partner', or 'roommate'). Fill only if 'Other (Describe relationship)' is 'Yes'. Depends on: Other (Describe relationship)
Work Limitation Description (How Conditions Limit Ability to Work)
How Your Conditions Limit Your Ability to Work	Text	Describe in detail how your illnesses, injuries, or conditions limit your ability to do work-related tasks — include specific symptoms, how often and how long they occur, activities or job duties affected, any positions or movements you cannot do, treatments or assistive devices you use, and examples of how these limits affect a typical workday or workweek.

Form SSA-3373, Function Report - Adult Instructions