Surveypoint

Q1

1. NAME OF DISABLED PERSON (First, Middle Initial, Last)

Q2

Your Number

Q3

4. a. Where do you live? Check one

Q4

b. With whom do you live? Check one

Q5

Form SSA-3373-BK (10-2015) UF (10-2015) Use (01-2013) ef (01-2013) Edition until Stock is Exhausted

Q6

6. Describe what you do from the time you wake up until going to bed.

Q7

7. Do you take care of anyone else such as a wife/husband, children, grandchildren,

Q8

If "YES," for whom do you care, and what do you do for them?

Q9

8. Do you take care of pets or other animals?

Q10

If "YES," what do you do for them?

Q11

9. Does anyone help you care for other people or animals?

Q12

If "YES," who helps, and what do they do to help?

Q13

10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?

Q14

11. Do the illnesses, injuries, or conditions affect your sleep?

Q15

If "YES," how?

Q16

12. PERSONAL CARE

Q17

Dress

Q18

Bathe

Q19

Care for hair

Q20

Shave

Q21

Feed self

Q22

Use the toilet

Q23

Other

Q24

b. Do you need any special reminders to take care of personal

Q25

If "YES," what type of help or reminders are needed?

Q26

c. Do you need help or reminders taking medicine?

Q27

If "YES," what kind of help do you need?

Q28

a. Do you prepare your own meals?

Q29

If "Yes," what kind of food do you prepare? For example, sandwiches, frozen dinners, or complete meals with several courses

Q30

How often do you prepare food or meals? For example, daily, weekly, monthly

Q31

How long does it take you?

Q32

Any changes in cooking habits since the illness, injuries, or conditions began?

Q33

b. If "No," explain why you cannot or do not prepare meals.

Q34

a. List household chores, both indoors and outdoors, that you are able to do. For example, cleaning, laundry, household repairs, ironing, mowing, etc

Q35

b. How much time does it take you, and how often do you do each of these things?

Q36

c. Do you need help or encouragement doing these things?

Q37

If "YES," what help is needed?

Q38

d. If you don't do house or yard work, explain why not.

Q39

a. How often do you go outside?

Q40

If you don't go out at all, explain why not.

Q41

b. When going out, how do you travel? Check all that apply

Q42

c. When going out, can you go out alone?

Q43

If "NO," explain why you can't go out alone.

Q44

d. Do you drive?

Q45

If you don't drive, explain why not.

Q46

a. If you do any shopping, do you shop: Check all that apply

Q47

b. Describe what you shop for.

Q48

c. How often do you shop and how long does it take?

Q49

Handle a savings account

Q50

Explain all "NO" answers.

Q51

b. Has your ability to handle money changed since the illnesses,

Q52

If "YES," explain how the ability to handle money has changed.

Q53

a. What are your hobbies and interests? For example, reading, watching TV, sewing, playing sports, etc

Q54

b. How often and how well do you do these things?

Q55

c. Describe any changes in these activities since the illnesses, injuries, or conditions began.

Q56

a. Do you spend time with others? In person, on the phone, on the computer, etc

Q57

If "YES," describe the kinds of things you do with others.

Q58

How often do you do these things?

Q59

b. List the places you go on a regular basis. For example, church, community center, sports events, social groups, etc

Q60

Do you need to be reminded to go places?

Q61

How often do you go and how much do you take part?

Q62

Do you need someone to accompany you?

Q63

c. Do you have any problems getting along with family, friends, neighbors,

Q64

If "YES," explain.

Q65

d. Describe any changes in social activities since the illnesses, injuries, or conditions began.

Q66

20. a. Check any of the following items that your illnesses, injuries, or conditions affect:

Q67

Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For example, you can only lift [how many pounds], or you can only walk [how far])

Q68

b. Are you:

Q69

c. How far can you walk before needing to stop and rest?

Q70

If you have to rest, how long before you can resume walking?

Q71

d. For how long can you pay attention?

Q72

e. Do you finish what you start? For example, a conversation, chores,

Q73

f. How well do you follow written instructions? For example, a recipe

Q74

g. How well do you follow spoken instructions?

Q75

h. How well do you get along with authority figures? For example, police, bosses, landlords or teachers

Q76

i. Have you ever been fired or laid off from a job because of problems getting

Q77

along with other people? If "YES," please explain.

Q78

If "YES," please give name of employer.

Q79

j. How well do you handle stress?

Q80

k. How well do you handle changes in routine?

Q81

l. Have you noticed any unusual behavior or fears?

Q82

If "YES," please explain.

Q83

21. Do you use any of the following? Check all that apply

Q84

Which of these were prescribed by a doctor?

Q85

When was it prescribed?

Q86

When do you need to use these aids?

Q87

22. Do you currently take any medicines for your illnesses, injuries, or conditions?

Q88

NAME OF MEDICINE

Q89

SIDE EFFECTS YOU HAVE

Q90

Is there anything else you would like us to know about why you cannot work full time?

Q91

Name of person completing this form (Please print)

Q92

Date (month, day, year)

Date

Q93

Address (Number and Street)

Q94

Email address

Q95

City

Q96

State

Q97

Function Report Adult -Form Fill