Adult Function Report
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Function Report
Name
First Name
Last Name
Social Security Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Number
Your Number
Message Number
None
Where do you live?
House
Apartment
Group Home
Boarding House
Nursing Home
Shelter
Other
With whom do you live?
Alone
With Family
With Friends
Other
How do your illnesses, injuries, or conditions limit your ability to work?
Describe what you do from the time you wake up until going to bed?
Do you take care of anyone else such as wife/husband, children, grandchildren, parents, friend, other?
Yes
No
If "Yes," for whom do you care, and what do you do for them?
Do you take care of pets or other animals?
Yes
No
If "YES," what do you do for them?
Does anyone help you care for other people or animals?
Yes
No
If "YES," who helps, and what do they do to help?
What were you able to do before your illnesses, injuries, or conditions that you can't do now?
Do the illnesses, injuries, or conditions affect your sleep?
Yes
No
If "YES," how?
Check here if NO PROBLEM with personal care
No problem
Dress
Bathe
Care for hair
Shave
Feed Self
Use the Toilet
Other
Do you need any special reminders to take care of personal needs and grooming?
Yes
No
If "YES," what type of help or reminders are needed?
Do you need help or reminders taking medicine?
Yes
No
If "YES," what kind of help do you need?
Do you prepare your own meals?
Yes
No
If "YES," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete meals with several courses.)
How often do you prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take you?
Any changes in cooking habits since the illness, injuries, or conditions began?
If "No," explain why you cannot or do not prepare meals.
List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)
How much time does it take you, and how often do you do each of these things?
Do you need help or encouragement doing these things?
Yes
No
If "YES," what help is needed?
If you don't do house or yard work, explain why not.
How often do you go outside?
If you don't go out at all, explain why not.
When going out, how do you travel? (Check all that apply.)
Walk
Drive a car
Ride in a car
Ride a bicycle
Use public transportation
Other
When going out, can you go out alone?
Yes
No
If "NO," explain why you can't go out alone.
Do you drive?
Yes
No
If you don't drive, explain why not.
If you do any shopping, do you shop: (check all that apply.)
In stores
By phone
By mail
By computer
Describe what you shop for.
How often do you shop and how long does it take?
Are you able to pay bills?
Yes
No
Are you able to count change?
Yes
No
Are you able to handle a savings account?
Yes
No
Are you able to use a checkbook/money orders?
Yes
No
Explain all "NO" answers.
Has your ability to handle money changed since the illnesses, injuries or conditions began?
Yes
No
If "YES," explain how the ability to handle money has changed?
What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
How often and how well do you do these things?
Describe any changes in these activities since the illnesses, injuries or conditions began.
How do you spend time with others? (Check all that apply.)
In person
On the phone
Email
Texting
Mail
Video chat (for example Skyope or Facetime)
Other
Describe the kinds of things you do with others.
How often do you do these things?
List the places you go on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Do you need to be reminded to go places?
Yes
No
How often do you go and how much do you take part?
Do you need someone to accompany you?
Yes
No
If "YES," explain.
Do you have any problems getting along with family, friends, neighbors, or others?
Yes
No
If "YES," explain
Describe any changes in social activities since the illnesses, injuries or conditions began.
Check any of the following items that your illnesses, injuries, or conditions affect:
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
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]).
Are you:
Right handed?
Left handed?
How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?
For how long can you pay attention?
Do you finish what you start? (For example, a conversation, chores, reading, watching a movie.)
Yes
No
How well do you follow written instructions? (For example, a recipe.)
How well do you follow spoken instructions?
How well do you get along with authority figures? (For example, police, bosses, landlords or teachers.)
Have you ever been fired or laid off a job because of problems getting along with other people?
Yes
No
If "YES," please explain.
If "YES," please give name of employer.
Type a question
Should be Empty: