DAILY ACTIVITIES WORKSHEET
Note: To print this form, please use the Text Only Daily Activities Worksheet.
NAME OF APPLICANT:
This Daily Activities Worksheet asks for information about your impairment that your doctor needs for an accurate report, and Social Security needs for understanding the impact of your illness/ injury.
A. HEIGHT - WEIGHT - DOMINANT HAND
1. Height (without shoes)?
2. Weight (without shoes)?
3. Dominant Hand: Right? Left? Both Equal?
B. ARE YOU WORKING?
1. Are you working?
2. If not, can you work all day, five days a week, year round?
3. Did your health stop you from working?
4. If so, when did you stop being able to work (month, day, year)?
C. ACTIVITIES OF DAILY LIVING
1. TYPICAL MONTH. Please state how many good, fair, and bad days you have each month. (Consider a month to be 30 continuous days.)
a. Good Days -- days when you do well and complete all living and home care activities. Total good days a month: _____
b. Fair Days -- days when you function with serious difficulty and fail to complete some living and home care activities. Total fair days a month: _____
c. Bad Days -- days when you function very poorly and fail to complete most living and home care activities. Total bad days a month: _____
d. Examples. In your own words please describe how the bad days and fair days are worse than the good ones.
e. Days WhenYou Must Stay Home -- Are there days when you don't go out because of your health? If yes, how many days a month does your health keep you in? _____ Please explain:
f. Progress of Impairment: Compared with a year ago, are you functioning: Better? Worse? About the same? Please explain.
2A. CARING FOR YOURSELF: PERSONAL NEEDS. Do you have serious difficulty taking care of any personal needs, including the following, due to your medical condition? (Check and describe any that apply, and give additional examples if these don't cover your situation.)
Using the toilet
Getting to the toilet
Holding onto objects
Taking medicines on time/in right dose
Doing things on time
Using the telephone
Caring for others
Group activities, like church or clubs
Other activities? Describe:
2B. MEALS. Do you prepare or serve meals? If so, what meals do you do?
(i) Breakfast. Describe what you do. How many days a month?
(ii) Lunch. Describe what you do. How many days a month?
(iii) Dinner. Describe what you do. How many days a month?
(iv) Helper(s). Does anyone help with meals? If yes, please explain what you do and what they do.
3. CARING FOR THE PLACE WHERE YOU LIVE.
a. Things You Do. Describe the home care activities you do regularly.
b. Things Other People Do. Describe the home care activities which other people do around the place you live.
c. Things That Don't Get Done. Describe any home care activities which need to be done, but do not get done because of your health.
d. Things You Don't Do Now. Did you do things in the past that you don't do now due to your health? If so, explain.
D. WORK RELATED ACTIVITIES.
Do you have serious difficulty doing any of the following on a sustained basis? (Describe any that apply.)
Pushing/pulling with hands
Pushing/pulling with legs
Reaching up, out, down
Grasping, handling, fingering
Keeping your balance
Traveling (driving or using public transportation)
Carrying out instructions
Finishing what you start
Getting along with people who supervise you
Getting along with people who annoy you
Adjusting to changes
Working productively all day, every day, year round
Functioning in bad environments (for example, risky places; environments of heat, cold, or humidity;
Other limitations? Describe:
E. DO YOU REMEMBER ANYTHING ELSE THAT MIGHT HELP YOUR DOCTOR OR SOCIAL SECURITY UNDERSTAND YOUR IMPAIRMENTS?
If yes, please explain.
The information listed above is complete and correct to the best of my knowledge.
Signature of Applicant ___________________________
Copyright 2013, Pds-Third Floor Publishing, LLC, All Rights Reserved
This Daily Activities Worksheet may be reproduced for personal use in connection with your claim. To request permission to distribute, write or e-mail us at the address below.
For more information, order the
Disability Workbook for Social Security Applicants, 8th Edition, 2012
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