Form SSA-3373, Function Report - Adult Instructions
This form contains 197 fields organized into 68 sections, giving it a Form Complexity Index of 72/100 (complex). Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 18. HOBBIES AND INTERESTS | ||
| Hobbies and Interests | Text |
List your hobbies and interests, such as reading, watching television, sewing, or playing sports.
|
| Frequency and Ability for Hobbies | Text |
Describe how often you participate in your hobbies and interests and how well you are able to do them. Fill only if 'Hobbies and Interests' has hobbies or interests listed.
Depends on:
Hobbies and Interests
|
| Changes in Hobbies and Interests | Text |
Describe any changes in your hobbies and interests since your illnesses, injuries, or conditions began. Fill only if 'Hobbies and Interests' has hobbies or interests listed.
Depends on:
Hobbies and Interests
|
| Abilities Before Illnesses or Injuries | ||
| Activities You Could Do Before Illness or Injury | Text |
Describe activities you were able to do before your illnesses, injuries, or conditions that you cannot do now.
|
| Activities With Others and Frequency | ||
| Activities Done With Others | Text |
Describe the kinds of activities you do with other people.
|
| Frequency of Activities With Others | Text |
State how often you do the activities with other people.
|
| Additional Remarks | ||
| Additional Remarks | Text |
Provide any additional information that was not included in earlier parts of the form.
|
| Affected Abilities and Explanation | ||
| Lifting | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to lift.
|
| Squatting | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to squat.
|
| Bending | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to bend.
|
| Standing | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to stand.
|
| Reaching | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to reach.
|
| Walking | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to walk.
|
| Sitting | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to sit.
|
| Kneeling | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to kneel.
|
| Talking | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to talk.
|
| Hearing | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to hear.
|
| Stair Climbing | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to climb stairs.
|
| Seeing | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to see.
|
| Memory | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your memory.
|
| Completing Tasks | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to complete tasks.
|
| Concentration | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to concentrate.
|
| Understanding | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to understand.
|
| Following Instructions | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to follow instructions.
|
| Using Hands | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to use your hands.
|
| Getting Along With Others | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your ability to get along with others.
|
| Affected Abilities Explanation | Text |
Explain how your illnesses, injuries, or conditions affect each ability you selected above. 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' (any).
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
|
| Assistive Devices and Usage Details | ||
| Crutches | Checkbox |
Check this box if you use crutches.
|
| Cane | Checkbox |
Check this box if you use a cane.
|
| Hearing Aid | Checkbox |
Check this box if you use a hearing aid.
|
| Walker | Checkbox |
Check this box if you use a walker.
|
| Brace/Splint | Checkbox |
Check this box if you use a brace or splint.
|
| Glasses/Contact Lenses | Checkbox |
Check this box if you use glasses or contact lenses.
|
| Wheelchair | Checkbox |
Check this box if you use a wheelchair.
|
| Artificial Limb | Checkbox |
Check this box if you use an artificial limb.
|
| Artificial Voice Box | Checkbox |
Check this box if you use an artificial voice box.
|
| Other (Explain) | Checkbox |
Check this box if you use another assistive device not listed above, and explain what it is.
|
| Other Assistive Device | Text |
Specify any other assistive device you use that is not listed. Fill only if 'Other (Explain)' is 'Yes'.
Depends on:
Other (Explain)
|
| Doctor-Prescribed Assistive Devices | Text |
List the assistive devices you use that were prescribed by a doctor.
|
| Assistive Device Prescription Date | Date |
Provide the date the listed assistive device or devices were prescribed.
|
| Assistive Device Usage Needs | Text |
Describe when or under what circumstances you need to use these assistive devices.
|
| Attention Span | ||
| Attention Span Duration | Text |
Enter how long you can pay attention before needing a break or losing focus.
|
| Care for Other People | ||
| Yes | Checkbox |
Check this box if you take care of anyone else, such as a spouse, child, grandchild, parent, friend, or another person.
|
| No | Checkbox |
Check this box if you do not take care of anyone else.
|
| Care Provided to Other People | Text |
Describe the people you care for and the assistance or care you provide to them. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Care for Pets or Animals | ||
| Yes | Checkbox |
Check this box if you take care of pets or other animals.
|
| No | Checkbox |
Check this box if you do not take care of pets or other animals.
|
| Pet or Animal Care Details | Text |
Describe the care you provide for your pets or other animals, including the tasks you perform for them. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Change in Money Handling Ability | ||
| Yes | Checkbox |
Check this box if your ability to handle money has changed since your illnesses, injuries, or conditions began.
|
| No | Checkbox |
Check this box if your ability to handle money has not changed since your illnesses, injuries, or conditions began.
|
| Explanation of Change in Money Handling Ability | Text |
Explain how your ability to handle money has changed since your illnesses, injuries, or conditions began. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Changes in Social Activities | ||
| Changes in Social Activities | Text |
Describe any changes in your social activities since your illnesses, injuries, or conditions began.
|
| Checkbook or Money Orders Ability | ||
| Use a checkbook/money orders — Yes | Checkbox |
Check this box if you are able to use a checkbook or money orders.
|
| Use a checkbook/money orders — No | Checkbox |
Check this box if you are not able to use a checkbook or money orders.
|
| Count Change Ability | ||
| Count change — Yes | Checkbox |
Check this box if you are able to count change.
|
| Count change — No | Checkbox |
Check this box if you are not able to count change.
|
| Currently Taking Medicines | ||
| Yes | Checkbox |
Check this box if you currently take any medicines for your illnesses, injuries, or conditions.
|
| No | Checkbox |
Check this box if you do not currently take any medicines for your illnesses, injuries, or conditions.
|
| Daily Activities Description | ||
| Daily Activities Description | Text |
Describe what you do during a typical day from the time you wake up until you go to bed.
|
| Daytime Telephone Contact | ||
| Daytime Telephone Area Code | Text |
Enter the area code for the daytime telephone number where you can be reached or where a message can be left.
|
| Daytime Telephone Number | Text |
Enter the phone number for the daytime telephone contact where you can be reached or where a message can be left.
|
| Your Number | Checkbox |
Check this box if the daytime telephone number you provide is your own number where you can be reached.
|
| Message Number | Checkbox |
Check this box if the daytime telephone number you provide is a number where someone can take a message for you.
|
| None | Checkbox |
Check this box if there is no daytime telephone number where you can be reached or where a message can be left for you.
|
| Disabled Person Identification | ||
| Disabled Person Name | Text |
Enter the disabled person's first name, middle initial, and last name.
|
| Social Security Number | Text |
Enter the disabled person's Social Security number.
|
| Driving Status and Explanation | ||
| Yes, I drive | Checkbox |
Check this box if you currently drive.
|
| No, I do not drive | Checkbox |
Check this box if you do not drive, and explain why in the space provided.
|
| Reason You Do Not Drive | Text |
Explain why you do not drive. Fill only if 'No, I do not drive' is 'Yes'.
Depends on:
No, I do not drive
|
| Explanation of No Money Ability Answers | ||
| Explanation of No Money Ability Answers | Text |
Explain why you answered no to any of the listed money-management abilities, such as paying bills, counting change, handling a savings account, or using a checkbook or money orders. Fill only if 'Pay bills — No', 'Count change — No', 'Handle a savings account — No', 'Use a checkbook/money orders — No' any is 'No'.
Depends on:
Pay bills — No, Count change — No, Handle a savings account — No, Use a checkbook/money orders — No
|
| Fifth Medicine Side Effects Entry | ||
| Fifth Medicine Name | Text |
Enter the name of the fifth medicine that causes side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fifth Medicine Side Effects | Text |
Describe the side effects you have from the fifth medicine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Medicine Side Effects Entry | ||
| First Medicine Name | Text |
Enter the name of the first medicine that causes side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| First Medicine Side Effects | Text |
Describe the side effects you have from the first medicine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Following Spoken Instructions | ||
| Ability to Follow Spoken Instructions | Text |
Describe how well you are able to follow spoken instructions.
|
| Following Written Instructions | ||
| Ability to Follow Written Instructions | Text |
Describe how well you are able to follow written instructions, such as a recipe.
|
| Form Completer Contact Information | ||
| Email Address | Text |
Enter the email address of the person completing this form, if applicable.
|
| Street Address | Text |
Enter the street number and street name for the person completing this form.
|
| City | Text |
Enter the city for the address of the person completing this form.
|
| State | Text |
Enter the state for the address of the person completing this form.
|
| ZIP Code | Text |
Enter the ZIP code for the address of the person completing this form.
|
| Form Completer Name and Date | ||
| Name of Person Completing Form | Text |
Enter the printed name of the person completing this form.
|
| Completion Date | Date |
Enter the date the person completed this form.
|
| Fourth Medicine Side Effects Entry | ||
| Fourth Medicine Name | Text |
Enter the name of the fourth medicine that causes side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fourth Medicine Side Effects | Text |
Describe the side effects you have from the fourth medicine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Frequency and Participation in Going Places | ||
| Frequency and Participation in Going Places | Text |
Describe how often you go to places and the extent to which you participate in activities there.
|
| Getting Along With Authority Figures | ||
| Ability to Get Along With Authority Figures | Text |
Describe how well you get along with authority figures, such as police officers, bosses, landlords, or teachers.
|
| Going Out Alone and Explanation | ||
| Yes | Checkbox |
Check this box if you can go out alone.
|
| No | Checkbox |
Check this box if you cannot go out alone; explain why in the space provided.
|
| Reason Cannot Go Out Alone | Text |
Explain why you cannot go out alone. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Going Outside Frequency and Explanation | ||
| Going Outside Frequency | Text |
Enter how often you go outside.
|
| Reason for Not Going Outside | Text |
Explain why you do not go outside at all. Fill only if 'Going Outside Frequency' indicates you don't go out at all.
Depends on:
Going Outside Frequency
|
| Handedness | ||
| Right Handed | Checkbox |
Check this box if you are right-handed.
|
| Left Handed | Checkbox |
Check this box if you are left-handed.
|
| Handling Changes in Routine | ||
| Ability to Handle Changes in Routine | Text |
Describe how well you handle changes in your usual routine.
|
| Handling Stress | ||
| Ability to Handle Stress | Text |
Describe how well you handle stress and any difficulties you experience when under stress.
|
| Help Caring for People or Animals | ||
| Yes — Someone helps care for other people or animals | Checkbox |
Check this box if someone helps you care for other people or animals.
|
| No — No one helps care for other people or animals | Checkbox |
Check this box if no one helps you care for other people or animals.
|
| Help Caring for People or Animals | Text |
Enter who helps you care for other people or animals and describe what each person does to help. Fill only if 'Yes — Someone helps care for other people or animals' is 'Yes'.
Depends on:
Yes — Someone helps care for other people or animals
|
| Help or Encouragement Needed for House or Yard Work | ||
| Yes | Checkbox |
Check this box if you need help or encouragement to do house or yard work.
|
| No | Checkbox |
Check this box if you do not need help or encouragement to do house or yard work.
|
| Help or Encouragement Needed for House or Yard Work | Text |
Describe the help or encouragement you need to perform household chores or yard work. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Household Chore Time and Frequency | ||
| Household Chore Time and Frequency | Text |
Describe how much time each household or yard chore takes and how often you perform each chore.
|
| Household Chores You Can Do | ||
| Household Chores You Can Do | Text |
List the indoor and outdoor household chores you are able to do, such as cleaning, laundry, repairs, ironing, or mowing.
|
| Job Loss Due to Problems Getting Along With Others | ||
| Yes | Checkbox |
Check this box if you have ever been fired or laid off from a job because of problems getting along with other people.
|
| No | Checkbox |
Check this box if you have never been fired or laid off from a job because of problems getting along with other people.
|
| Job Loss Explanation | Text |
Explain how problems getting along with other people led to you being fired or laid off from a job. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Employer Name | Text |
Provide the name of the employer where you were fired or laid off because of problems getting along with others. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Living Arrangement | ||
| Alone | Checkbox |
Check this box if you live alone.
|
| With Family | Checkbox |
Check this box if you live with family members.
|
| With Friends | Checkbox |
Check this box if you live with friends.
|
| Other | Checkbox |
Check this box if you live with someone other than family or friends, and describe your relationship.
|
| Other Household Relationship | Text |
Describe your relationship to the other person or people you live with. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Meal Preparation Ability and Yes Details | ||
| Prepare Your Own Meals - Yes | Checkbox |
Check this box if you prepare your own meals.
|
| Prepare Your Own Meals - No | Checkbox |
Check this box if you do not prepare your own meals.
|
| Types of Meals Prepared | Text |
Describe the kinds of food or meals you prepare, such as sandwiches, frozen dinners, or complete meals. Fill only if 'Prepare Your Own Meals - Yes' is 'Yes'.
Depends on:
Prepare Your Own Meals - Yes
|
| Meal Preparation Frequency | Text |
State how often you prepare food or meals, such as daily, weekly, or monthly. Fill only if 'Prepare Your Own Meals - Yes' is 'Yes'.
Depends on:
Prepare Your Own Meals - Yes
|
| Meal Preparation Duration | Text |
State how long it usually takes you to prepare food or meals. Fill only if 'Prepare Your Own Meals - Yes' is 'Yes'.
Depends on:
Prepare Your Own Meals - Yes
|
| Changes in Cooking Habits | Text |
Describe any changes in your cooking habits since your illnesses, injuries, or conditions began. Fill only if 'Prepare Your Own Meals - Yes' is 'Yes'.
Depends on:
Prepare Your Own Meals - Yes
|
| Medication Help or Reminders Needed | ||
| Yes - Need Help or Reminders Taking Medicine | Checkbox |
Check this box if you need another person’s help or reminders to take your medicine.
|
| No - Need Help or Reminders Taking Medicine | Checkbox |
Check this box if you do not need help or reminders to take your medicine.
|
| Medication Help or Reminders Needed | Text |
Describe the type of help or reminders you need to take your medicine. Fill only if 'Yes - Need Help or Reminders Taking Medicine' is 'Yes'.
Depends on:
Yes - Need Help or Reminders Taking Medicine
|
| Medicines Causing Side Effects | ||
| Yes | Checkbox |
Check this box if any of the medicines you take cause side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Checkbox |
Check this box if none of the medicines you take cause side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Need Someone to Accompany You | ||
| Yes | Checkbox |
Check this box if you need someone to accompany you when you go places.
|
| No | Checkbox |
Check this box if you do not need someone to accompany you when you go places.
|
| Need for Accompaniment Explanation | Text |
Explain why you need someone to accompany you when you go places. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Page 1 | ||
| Page 1 text entry | Text |
Enter the information requested in this text field on page 1.
|
| Pay Bills Ability | ||
| Pay bills — Yes | Checkbox |
Check this box if you are able to pay bills.
|
| Pay bills — No | Checkbox |
Check this box if you are not able to pay bills.
|
| Personal Care Difficulties and No Problem Option | ||
| Dressing Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to dress yourself. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Bathing Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to bathe yourself. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Hair Care Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to care for your hair. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Shaving Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to shave. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Feeding Yourself Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to feed yourself. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Toilet Use Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect your ability to use the toilet. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| Other Personal Care Difficulties | Text |
Describe how your illnesses, injuries, or conditions affect any other personal care activity not listed above. Fill only if 'No Problem with Personal Care' is 'No'.
Depends on:
No Problem with Personal Care
|
| No Problem with Personal Care | Checkbox |
Check this box if your illnesses, injuries, or conditions cause no problems with your personal care.
|
| Personal Care Reminders Needed | ||
| Yes | Checkbox |
Check this box if you need special reminders to take care of your personal needs or grooming.
|
| No | Checkbox |
Check this box if you do not need special reminders to take care of your personal needs or grooming.
|
| Personal Care Reminders Needed | Text |
Describe the help or reminders you need to take care of your personal needs and grooming. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Privacy Act Statements Collection and Use of Personal Information | ||
| Page 2 of 10 Privacy Act Statements Collection and Use of Personal Information Sections 205(ay), 223(d), and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed. We will use the information you provide to determine benefits eligibility. We may also share the information for the following purposes, called routine uses: • To third party contacts (e.g., employers and private pension plans) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his or her benefits or payments, or his or her eligibility for entitlement to benefits or eligibility for payments, under the Social Security program; and • To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (S S A) in the efficient administration of its programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system record. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of additional routine uses is available in our Privacy Act System of Records Notices (S O R N) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on June 6, 2020 at 85 FR 34477. Additional information, and a full listing of all of our S O R N s, is available on our website at www.ssa.gov/privacy | Text | |
| Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 61 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate or other aspects of this collection to this address, not the completed form. PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM | Text | |
| Problems Getting Along With Others | ||
| Yes | Checkbox |
Check this box if you have any problems getting along with family, friends, neighbors, or others.
|
| No | Checkbox |
Check this box if you do not have any problems getting along with family, friends, neighbors, or others.
|
| Problems Getting Along With Others Explanation | Text |
Explain any problems you have getting along with family, friends, neighbors, or other people. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Not Doing House or Yard Work | ||
| Reason for Not Doing House or Yard Work | Text |
Explain why you do not do house or yard work.
|
| Reason for Not Preparing Meals | ||
| Reason for Not Preparing Meals | Text |
Explain why you cannot or do not prepare your own meals. Fill only if 'Prepare Your Own Meals - No' is 'No'.
Depends on:
Prepare Your Own Meals - No
|
| Regular Places Visited | ||
| Regular Places Visited | Text |
List the places you go on a regular basis, such as church, a community center, sports events, or social groups.
|
| Reminder Needed to Go Places | ||
| Yes | Checkbox |
Check this box if you need to be reminded to go places.
|
| No | Checkbox |
Check this box if you do not need to be reminded to go places.
|
| Residence Type | ||
| House | Checkbox |
Check this box if you live in a house.
|
| Apartment | Checkbox |
Check this box if you live in an apartment.
|
| Boarding House | Checkbox |
Check this box if you live in a boarding house.
|
| Nursing Home | Checkbox |
Check this box if you live in a nursing home.
|
| Shelter | Checkbox |
Check this box if you live in a shelter.
|
| Group Home | Checkbox |
Check this box if you live in a group home.
|
| Other | Checkbox |
Check this box if your residence type is not listed and describe it in the space provided.
|
| Other Residence Type | Text |
Specify the type of residence where you live if it is not a house, apartment, boarding house, nursing home, shelter, or group home. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Rest Duration Before Resuming Walking | ||
| Rest Duration Before Resuming Walking | Text |
Enter how long you must rest before you are able to resume walking.
|
| Savings Account Ability | ||
| Handle a savings account — Yes | Checkbox |
Check this box if you are able to handle a savings account.
|
| Handle a savings account — No | Checkbox |
Check this box if you are not able to handle a savings account.
|
| Second Medicine Side Effects Entry | ||
| Second Medicine Name | Text |
Enter the name of the second medicine that causes side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Second Medicine Side Effects | Text |
Describe the side effects you have from the second medicine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS | ||
| How Illnesses Limit Ability to Work | Text |
Describe how your illnesses, injuries, or conditions limit your ability to work.
|
| Shopping Description | ||
| Shopping Description | Text |
Describe the items, goods, or services you shop for. Fill only if 'In stores', 'By phone', 'By mail', 'By computer' is 'Yes' (any fields selection).
Depends on:
In stores, By phone, By mail, By computer
|
| Shopping Frequency and Duration | ||
| Shopping Frequency and Duration | Text |
Describe how often you shop and how long a typical shopping trip takes. Fill only if 'In stores', 'By phone', 'By mail', 'By computer' is 'Yes' (any fields selection).
Depends on:
In stores, By phone, By mail, By computer
|
| Shopping Methods | ||
| In stores | Checkbox |
Check this box if you do any of your shopping in physical stores.
|
| By phone | Checkbox |
Check this box if you do any of your shopping by phone.
|
| By mail | Checkbox |
Check this box if you do any of your shopping by mail.
|
| By computer | Checkbox |
Check this box if you do any of your shopping using a computer.
|
| Sleep Affected by Illnesses or Conditions | ||
| Yes | Checkbox |
Check this box if your illnesses, injuries, or conditions affect your sleep.
|
| No | Checkbox |
Check this box if your illnesses, injuries, or conditions do not affect your sleep.
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| How Illnesses or Conditions Affect Sleep | Text |
Describe how your illnesses, injuries, or conditions affect your sleep. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
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| Task Completion | ||
| Yes | Checkbox |
Check this box if you usually finish what you start, such as conversations, chores, reading, or watching a movie.
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| No | Checkbox |
Check this box if you do not usually finish what you start, such as conversations, chores, reading, or watching a movie.
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| Third Medicine Side Effects Entry | ||
| Third Medicine Name | Text |
Enter the name of the third medicine that causes side effects. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
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| Third Medicine Side Effects | Text |
Describe the side effects you have from the third medicine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
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| Travel Methods and Other Transportation Explanation | ||
| Walk | Checkbox |
Check this box if you travel by walking when you go out.
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| Drive a car | Checkbox |
Check this box if you drive a car when you go out.
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| Ride in a car | Checkbox |
Check this box if you ride as a passenger in a car when you go out.
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| Ride a bicycle | Checkbox |
Check this box if you travel by bicycle when you go out.
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| Use public transportation | Checkbox |
Check this box if you use public transportation when you go out.
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| Other (Explain) | Checkbox |
Check this box if you use another method of travel not listed, and explain the method.
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| Other Transportation Method Explanation | Text |
Describe the other method of transportation you use when going out. Fill only if 'Other (Explain)' is 'Yes'.
Depends on:
Other (Explain)
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| Unusual Behavior or Fears | ||
| Yes | Checkbox |
Check this box if you have noticed any unusual behavior or fears.
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| No | Checkbox |
Check this box if you have not noticed any unusual behavior or fears.
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| Unusual Behavior or Fears Explanation | Text |
Explain any unusual behaviors or fears you have noticed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
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| Walking Distance Before Rest | ||
| Walking Distance Before Rest | Text |
Enter the distance you can walk before needing to stop and rest.
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| Ways of Spending Time With Others | ||
| In person | Checkbox |
Check this box if you spend time with other people in person.
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| On the phone | Checkbox |
Check this box if you spend time with other people by talking on the phone.
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| Checkbox |
Check this box if you spend time with other people through email.
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| Texting | Checkbox |
Check this box if you spend time with other people by text messaging.
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| Checkbox |
Check this box if you spend time with other people through mailed letters or cards.
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| Other (Explain) | Checkbox |
Check this box if you spend time with others in another way not listed, and explain the method.
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| Other Way of Spending Time With Others | Text |
Describe any other way you spend time with other people that is not listed above. Fill only if 'Other (Explain)' is 'Yes'.
Depends on:
Other (Explain)
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| Video Chat (for example Skype or Facetime) | Checkbox |
Check this box if you spend time with other people using video chat, such as Skype or FaceTime.
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