SSA-3373-BK

FUNCTION REPORT - ADULT - Form SSA-3373-BK


READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can. It is important that you tell us about your activities and abilities

It is important that you tell us about your activities and abilities

  • Print or type.
  • DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is "none" or "does not apply," please write "don't know" or "none" or "does not apply."
  • Do not ask a doctor or hospital to complete this form.
  • Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer.
  • If more space is needed to answer any questions, use the "REMARKS" section on Page 8, and show the number of the question being answered.








REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 8









Form Approved
OMB No. 0960-0681

SOCIAL SECURITY ADMINISTRATION


FUNCTION REPORT - ADULT

How your illnesses, injuries, or conditions limit your activities


For SSA Use Only Do not write in this box.









Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.


SECTION A - GENERAL INFORMATION


1. NAME OF DISABLED PERSON (First, Middle Initial, Last)


2. SOCIAL SECURITY NUMBER



3. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached,
please give us a daytime number where we can leave a message for you.)


Your NumberMessage NumberNone

Phone NumberArea Code



4. a. Where do you live? (Check one.)

House Apartment Boarding House Nursing Home
Shelter Group Home Other


4b. With whom do you live? (Check one.)

Alone With Family With Friends
Other (Describe relationship.)

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


5. How do your illnesses, injuries, or conditions limit your ability to work?



SECTION C - INFORMATION ABOUT DAILY ACTIVITIES


6. Describe what you do from the time you wake up until going to bed.



7. Do you take care of anyone else such as a wife/husband, children, grandchildren, parents, friend, other?YesNo

If "YES," for whom do you care, and what do you do for them?



8. Do you take care of pets or other animals?YesNo

If "YES," what do you do for them?



9. Does anyone help you care for other people or animals?YesNo

If "YES," who helps, and what do they do to help?



10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?



11. Do the illnesses, injuries, or conditions affect your sleep?YesNo

If "YES," how?



12. PERSONAL CARE (Check here if NO PROBLEM with personal care.

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








b. Do you need any special reminders to take care of personal needs and grooming?YesNo

If "YES," what type of help or reminders are needed?



c. Do you need help or reminders taking medicine?YesNo

If "YES," what kind of help do you need?



13. MEALS

a. Do you prepare your own meals?YesNo

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?




b. If "No," explain why you cannot or do not prepare meals.



14. HOUSE AND YARD WORK

a. List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)



b. How much time does it take you, and how often do you do each of these things?



c. Do you need help or encouragement doing these things?YesNo
If "YES," what help is needed?



d. If you don't do house or yard work, explain why not.

15. GETTING AROUND

a. How often do you go outside?

If you don't go out at all, explain why not.

b. 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 (Describe relationship.)

c. When going out, can you go out alone?YesNo


If "NO," explain why you can't go out alone.

d. Do you drive?YesNo
If you don't drive, explain why not.

16. SHOPPING

a. If you do any shopping, do you shop: (Check all that apply.)

In stores By phone By mail By computer

b. Describe what you shop for.

c. How often do you shop and how long does it take?

17. MONEY

a. Are you able to:

YesNo YesNo
YesNo YesNo

Explain all "NO" answers

b. Has your ability to handle money changed since the illnesses, injuries, or conditions began?YesNo

If "YES," explain how the ability to handle money has changed.

18. HOBBIES AND INTERESTS

a. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)

b. How often and how well do you do these things?

c. Describe any changes in these activities since the illnesses, injuries, or conditions began.

19. SOCIAL ACTIVITIES

a. Do you spend time with others? (In person, on the phone, on the computer, etc.)YesNo

If "YES," describe the kinds of things you do with others.

How often do you do these things?

b. 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?YesNo

How often do you go and how much do you take part?

Do you need someone to accompany you?YesNo

c. Do you have any problems getting along with family, friends, neighbors, or others?YesNo

If "YES," explain.

d. Describe any changes in social activities since the illnesses, injuries, or conditions began.


SECTION D - INFORMATION ABOUT ABILITIES


20. a. 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])

b. Are you:Right handed?Left handed?

c. How far can you walk before needing to stop and rest?

If you have to rest, how long before you can resume walking?

d. For how long can you pay attention?

e. Do you finish what you start? (For example, a conversation, chores, YesNo reading, watching a movie.)

f. How well do you follow written instructions? (For example, a recipe.)?

g. How well do you follow spoken instructions?

h. How well do you get along with authority figures? (For example, police, bosses, landlords or teachers.)

i. Have you ever been fired or laid off from a job because of problems getting along with other people?YesNo

If "YES," explain.

If "YES," please give name of employer.

j. How well do you handle stress?

k. How well do you handle changes in routine?

l. Have you noticed any unusual behavior or fears?YesNo

If "YES," explain.

21. Do you use any of the following? (Check all that apply.)

Crutches
Walker
Wheelchair
Other: (Explain)
Cane
Brace
Splint
Artifical Limb
Hearing Aid
Glasses/Contact Lenses
Artificial Voice Box


Which of these were prescribed by a doctor?

When was it prescribed?

When do you need to use these aids?

22. Do you currently take any medicines for your illnesses, injuries, or conditions?YesNo

If "YES, "do any of your medicines cause side effects?YesNo

If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that cause side effects.)

MEDICATION SIDE EFFECTS

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.




Name of person completing this form (Please print)Date (month, day, year)

Address (Number and Street)Email address (optional)

City, State, Zip



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