If you think you might have difficulty at your Social Security disability hearing describing how your impairment has changed your life, completing this activities questionnaire a few days before your hearing is likely to be helpful. You can also download and print the full PDF version of the Social Security Disability Activities Questionnaire.

To: ___________________________________

___________________________________

___________________________________

Your disability hearing will be held soon. Please complete this Activities Questionnaire and bring it to the meeting we have scheduled to prepare you to testify.

Read through this form before you fill it out. Spend a few days thinking about the activities listed on the form and the many ways your life has changed because of your health problems. Talk with family members and friends about their observations. Then, in the days before you meet with us, complete the form in as much detail as possible.

For each of the activities listed, describe the way these things are done differently now (or not performed at all) compared to the way they were performed before you became disabled. For each activity, some possibilities are suggested in parentheses; but these are only suggestions to start you thinking. List changes in the way the activities are performed, however small the difference may seem. If you now perform these activities only on “good days,” be sure to say so. State the reasons the activities are now performed differently. Explain. The details help.

Thank you.

1. Driving (no longer drive, drive less often, drive only short distances, difficulty getting into or out of the car, got handicapped parking permit, get lost while driving, use bigger car, accidents, make frequent stops):






2. Cooking and eating (no longer cook, cook less often, cook simpler meals, cook only for myself, eat out more, skip meals, burn food, no appetite, drop cooking utensils, sit while cooking):






3. Wash dishes (no longer wash dishes, wash less often, drop dishes, sit while washing dishes, only wash a few dishes at a time, let dirty dishes pile up, bought a dishwasher):






4. Straighten up house (house more of a mess, others help with cleaning, hired house-cleaner, rest after short periods of cleaning):






5. Dust:



6. Vacuum:



7. Mop floor (use stick mop instead of scrubbing floor while kneeling):



8. Laundry including washing, drying, ironing, folding (wash clothes less often, get assistance doing or carrying laundry, throw rather than carry laundry down the steps, stay in basement while doing laundry, carry only a few items at a time, take more clothes to cleaner, buy more permanent press clothes):






9. Clean bathroom:



10. Make bed:



11. Yard work including cutting grass, bagging clippings, gardening, raking, etc. (others cut grass, use self-propelled mower, stopped gardening, moved into condo):



12. Shovel snow:



13. Fix things:




14. Grocery shop (do not shop alone, shop when crowds are smaller and lines shorter, rest while shopping, lean on car, smaller bags, use express checkout, delivery by store, buy smaller containers, get dropped off and picked up at store entrance, buy more convenience foods such as TV dinners, sandwiches, microwave foods):






15. Pay bills / handle finances:






16. Watch / play with children:




17. Watch TV / listen to radio (watch more, TV no longer keeps my interest, trouble concentrating on what is going on, shorter attention span, watch more while in bed or on recliner, more frequent breaks, nose makes me nervous):






18. Read (need to reread sections to understand, do not remember what was read, read for shorter periods of time, read shorter pieces such as magazines instead of novels, stopped reading the newspaper):




19. Talk with others, including telephone (want to be left alone, initiate conversations less often, talk for shorter periods of time):




20. Sleep at night (different times to go to bed and get up, trouble falling asleep, restlessness, get out of bed during night, inability to sustain sleep, feel tired when getting up, use sleeping pills, extra pillows under head or legs):






21. Sleep/rest during day (naps, rest periods, time spent in bed, couch or recliner):




22. Dress and groom self such as brush teeth, shave, wash, use toilet, comb hair, makeup applications, shower, bathe (groom self less often, need reminders, guardrails in tub, others comb and wash hair, lean against sink while brushing teeth and shaving, shorter showers):






23. Go to church:



24. Participate in clubs, organizations, or church activities:




25. Use public transportation (use bus schedules to reduce waiting time, sit on benches, hold onto rails while climbing steps, sit in front of bus, get ride to bus stop, ride bus when less crowded):




26. Exercising:



27. Visit and activities with friends, neighbors, family, relatives (visit less often or for shorter periods, others come to my house, they visit in my bedroom or while I am lying down):





28. Play cards / games:



29. Attend sporting events / movies / go out to dinner:



30. Identify all interests and hobbies you used to enjoy. Why and how you do them differently now or not at all? (For example, fishing, crossword puzzles, hunting, sports, knitting, collecting, rummage sales, musical instruments, woodworking, golfing):









31. Writing:




32. Sitting (different chair / sofa, shorter periods, squirm, sit forward or lean to a side, elevate legs, difficulty arising from a chair, difficulties bending head down, using hands in front of myself, or reaching overhead while sitting, difficulty twisting while sitting):




33. Standing, walking and climbing steps (use cane, lean against walls or furniture, stumble into things, fall or almost fall):






34. Lift and carry (smaller items, hold against body):







35. Use arms / hands / fingers (drop things, can’t make fist, trembling or shaking, trouble picking up small items off the table, using hand tools, and opening containers, jars and doors, cannot reach into cupboards, write for short periods only, use slip-on instead of tie shoes, difficulty buttoning clothes):





36. “I can’t seem to get anything done on time.” (If this is true for you, explain why and give examples):






37. Leaving the home (less frequent walks, not leaving home alone):




38. Care for pets:




Other comments:




 

Get the printable Activities Questionnaire