• FUNCTION REPORT - ADULT

     

    HOW TO COMPLETE THIS FORM

    • TIME: This form should take about 15 minutes to complete. 
    • Instructions:
      • Answer each question to the best of your ability and do not leave any question blank. If you do not know the answer or have nothing to write, just put "none," "n/a," or "don't know."
      • If you run out of space in any answer, use the "REMARKS" section at the end to finish your answer, reference the number of the question being answered. 
      • HOWEVER, the best practice is to keep your responses short and sweet. 
      • Your answers will be used by SSA to help make a determination on your claim. Answer honestly based on how our fay-to-day life actually is, NOT how it is only on your best days or how you wish it would be, and do not over-embellish either. 
      • At the end of the form you will be asked to list the person that filled the form out, if it was YOU, put your name and address; if it was someone else at your direction, list THEIR name and address.

     

  • SECTION A - GENERAL INFORMATION

  • Format: (000) 000-0000.
  • *
  • Are you (the disabled claimant) completing this form or is someone else doing it for you?
  • 4. a. Where do you live? (Check one)*
  • b. Who do you live with?*

  • SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS

  • 0/1200

  • SECTION C - INFORMATION ABOUT DAILY ACTIVITIES

  • 0/500
  • 7. Do you care for anyone else in your household as the PRIMARY caregiver? (I.e. spouse, child, elderly, grandchildren)*
  • 0/200
  • 8. Do you take care of any PETS or animals?*
  • 0/200
  • 9. Does ANYONE ELSE help you care for these PETS or OTHERS in your household?
  • 0/160
  • 0/200
  • 11. Do your conditions affect your sleep?*
  • 0/120
  • 12. Do you need help with dressing, bathing, shaving, doing your hair, feeding yourself, or using the toilet?*

  • a. Explain how your illnesses, injuries, or conditions affect your ability to:

  • 0/100
  • 0/100
  • 0/150
  • 0/100
  • 0/100
  • 0/100
  • 0/120
  • b. Do you need to be reminded to bathe or take care of your personal hygiene?*
  • 0/300
  • c. Do you need help or reminders taking medicine?*
  • 0/400

  • 13. MEALS

  • 13. Do you prepare your own meals?*
  • 0/200
  • 0/100
  • 0/100
  • 0/400

  • 14. HOUSE AND YARD WORK

  • 14. Do you do household and yard work? (cleaning, laundry, mowing, etc.)*
  • 0/200
  • 0/200
  • c. Do you need help or encouragement doing these things?
  • 0/100
  • 0/200

  • 15. GETTING AROUND

  • 15. Do you go outside?*
  • 0/200
  • b. Do you drive?*
  • 0/400
  • c. How do you get places?*
  • d. Can you go places alone regularly?*
  • 0/250

  • 16. SHOPPING

  • Do you shop regularly?*
  • If you do any shopping, do you shop: (Check all that apply.)
  • 0/100
  • 0/200

  • 17. MONEY

    a. Are you able to, on your OWN (**regardless of how much money you have):

  • Count change:*
  • Use a checkbook/money orders:*
  • Handle a savings account:*
  • Pay bills on your own (regardless of whether you have enough money to):*
  • 0/100
  • b. Has your ability to handle money changed since the illnesses, injuries, or conditions began?*
  • 0/600

  • 18. HOBBIES AND INTERESTS

  • 0/300
  • 0/300
  • 0/300

  • 19. SOCIAL ACTIVITIES

  • a. How do you spend time with others? (Check all that apply.)*
  • 0/200
  • 0/60
  • 0/200
  • Do you need to be reminded to go places (like doctors appointments)?*
  • Do you need someone to accompany you places? (i.e. you cannot go places alone)?*
  • 0/300
  • d. Do you have any problems getting along with family, friends, neighbors, or coworkers?*
  • 0/300
  • 0/400

  • SECTION D - INFORMATION ABOUT ABILITIES

  • 20. a. Check any of the following items that your illnesses, injuries, or conditions affect:*
  • 0/390
  • b. Handedness*
  • 0/60
  • 0/200
  • 0/60
  • e. Do you finish what you start? (For example, a conversation, chores, reading, watching a movie.)*
  • 0/200
  • 0/300
  • 0/200
  • i. Have you ever been fired or laid off from a job because of problems getting along with other people?*
  • 0/600
  • 0/60
  • 0/100
  • 0/100
  • l. Have you noticed any unusual behavior or fears?*
  • 0/1000

  • 21. Assistive Devices

    21. Do you use any of the following assistive devices? Check ALL that apply. 

    NOTE: SSA's form only provides check boxes for certain devices even though many others exist. If you use any other assistive devices not listed, please write them in other.  Additional assistive devices may include:

    Adaptive bed, Adaptive utensils, Alert systems, CPAP machine, Dictation devices, Insulin pump, Other., Reachers/grabbers, Shower chair, Toilet bars, Voice-activated assistance, Zipper pulls, or something else.

  • 0/950
  • 0/300
  • 0/300
  • 22. Do you currently take any medicines for your illnesses, injuries, or conditions?*
  • Do any of your medicines cause side effects?
  • Rows

  • SECTION E - REMARKS

    Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this page.

  • 0/2000
  • Date Completed:*
     / /
  •  
  • Should be Empty: