EXERTION QUESTIONNAIRE SINCE YOUR DISABILITY BEGAN

EXERTION QUESTIONNAIRE SINCE YOUR DISABILITY BEGAN

The answers to these questions will help us find out if you are disabled within the meaning of the law. Please explain your answers by giving us detailed examples. If you need more room, you may use more sheets of paper. Be sure to sign and date this form at the end in the space provided.

1. Where do you live? (Circle ? if you circle other, explain)

HOUSE APARTMENT

BOARDING HOME NURSING HOME

OTHER

2. With whom do you live? (Circle ? if you circle other, explain)

ALONE

WITH FAMILY

WITH FRIENDS BOARD & CARE OTHER

3. Please describe your symptoms (such as pain, fatigue, weakness, dizziness, nausea, diarrhea, fevers, shortness of breath, effects of medication, etc.) that prevent you from carrying out your normal workday. Please be specific.

4. Please describe what kinds of things you do on an average day an how these activities make you feel.

5. How far do you walk and how long does it take you to walk this distance? Explain how you feel after walking this distance.

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6. Do you climb stairs? ! Yes ! No If YES, how many flights and how does this affect you? 7. What kind of things can you lift? How often? 8. What kind of things can you carry? How far? How often? 9. Do you do your own grocery shopping? ! Yes ! No If YES, please list the chores you do

and how long does it takes you to do them. 10. Do you clean your own home or living area? ! Yes ! No If YES, please list the chores you

do and how long does it take you to do them? 11. Do you drive a car? ! Yes ! No If YES, Manual or automatic? How far can you drive at one

time? 12. Do you work on cars? ! Yes ! No If YES, How often? What kinds of things do you do?

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13. Do you do yard work? ! Yes ! No If YES, describe what you do and how this affects you.

14. Did you do any of the above chores before you came disabled? ! Yes ! No If YES, are there any differences in the way you now do these chores and how the effort of doing them affects you.

15. Do you have difficulty finishing any of your housework or other chores? ! Yes ! No If YES, how long can you continue until you have to stop? What stops you?

16. How many hours to you sleep?

17. Do you require rest periods or naps during the day? ! Yes ! No If YES, how many? How long?

18. What medication(s) do you take for your condition? Please list the names, how much and how often you take them.

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19. Do you use splint brace cane crutch walker wheelchair If yes, explain for what purpose and how often?

20. Is there anything else you would like to tell us about your condition?

21. Have you attached supplemental sheets to this form? ! Yes ! No

________________________________________________ YOUR NAME

________________________________________________ YOUR SIGNATURE

___________ DATE

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