|
Disability Questionnaire (ver.5)
================================
HISTORY
1. Name _______________________________ Age ________
2. Life/Family
. Where born? ____________
. Immigration/s? (where and when)
_______________________________________________________
. Children/Spouse?
_______________________________________________________
. Present Co-habitants?
_______________________________________________________
. Other
_______________________________________________________
3. Education/Skills
. formal academic achievements(grade and where)?
_______________________________________________________
_______________________________________________________
speak? read? write?
4. Languages
-------------------------------------------------------
English | | |
-------------------------------------------------------
| | |
-------------------------------------------------------
| | |
-------------------------------------------------------
. driver's license? drive? If not, why not?
_______________________________________________________
2
5. Work and Income (from first to last)
Years/
Age Entity? What Did? How Long? Why Ended?
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
Notes
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
3
6. Functional Limitations
(a) Physical
Activity | Problems? | When | Notes |
| | Started? | |
===========================================================
Pain? | | | |
| | | |
-----------------------------------------------------------
Walking | | | |
| | | |
-----------------------------------------------------------
Standing | | | |
| | | |
-----------------------------------------------------------
Sitting | | | |
| | | |
-----------------------------------------------------------
Bending | | | |
| | | |
-----------------------------------------------------------
Carrying | | | |
| | | |
-----------------------------------------------------------
Lifting | | | |
| | | |
-----------------------------------------------------------
Dexterity | | | |
| | | |
-----------------------------------------------------------
Breathing | | | |
| | | |
-----------------------------------------------------------
Sleeping | | | |
| | | |
-----------------------------------------------------------
Toiletting| | | |
| | | |
-----------------------------------------------------------
Diet/ | | | |
Nutrition | | | |
-----------------------------------------------------------
Speaking | | | |
| | | |
-----------------------------------------------------------
4
-----------------------------------------------------------
Hearing | | | |
| | | |
-----------------------------------------------------------
Sight | | | |
| | | |
-----------------------------------------------------------
Nausea | | | |
| | | |
-----------------------------------------------------------
Headaches | | | |
| | | |
-----------------------------------------------------------
Dizziness | | | |
| | | |
-----------------------------------------------------------
Obesity | | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
Notes: ____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
5
(b) Self-Care
Activity | Problems? | When | Notes |
| | Started? | |
===========================================================
Feeding | | | |
Self | | | |
-----------------------------------------------------------
Washing/ | | | |
Bathing | | | |
-----------------------------------------------------------
Dressing | | | |
| | | |
-----------------------------------------------------------
Cooking | | | |
| | | |
-----------------------------------------------------------
Dishes | | | |
| | | |
-----------------------------------------------------------
Cleaning | | | |
| | | |
-----------------------------------------------------------
Laundry | | | |
| | | |
-----------------------------------------------------------
Shopping | | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
Notes: ____________________________________________________
____________________________________________________
____________________________________________________
6
(c) Community and Workplace Functioning
Activity | Problems? | When | Cause/Notes |
| | Started? | |
===========================================================
Ambulation| | | |
| | | |
-----------------------------------------------------------
Limits on | | | |
Going Out | | | |
-----------------------------------------------------------
Crowds | | | |
| | | |
-----------------------------------------------------------
Friends | | | |
| | | |
-----------------------------------------------------------
Parenting | | | |
| | | |
-----------------------------------------------------------
Clubs/ | | | |
Church | | | |
-----------------------------------------------------------
Social- | | | |
izing | | | |
-----------------------------------------------------------
Sexuality | | | |
| | | |
-----------------------------------------------------------
Anger & | | | |
Violence | | | |
-----------------------------------------------------------
Criminal | | | |
| | | |
-----------------------------------------------------------
Authority | | | |
Figures | | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
7
(d) Mental/Emotional
Activity | Problems? | When | Cause/Notes |
| | Started? | |
===========================================================
Concentra-| | | |
tion | | | |
-----------------------------------------------------------
Memory | | | |
| | | |
-----------------------------------------------------------
Anger/ | | | |
Meekness | | | |
-----------------------------------------------------------
Alcohol/ | | | |
Drug | | | |
-----------------------------------------------------------
Mood | | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
Notes _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
8
7. Treatment/Meds/Aids
Therapy - What and When Started?
Physio? __________________________________________________
Psycho? __________________________________________________
External Services Used - Which and When Started?
-----------------------------------------------------------
-----------------------------------------------------------
Prostheses Used - What and When Started?
(eg.cane, wheelchair, walker)
----------------------------------------------------------
----------------------------------------------------------
Medications
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
----------------------------------------------------------
Side Effects?
__________________________________________________________
9
WITNESS/ES
________________________ ________________ ____________
Name Relationship Phone/Contact
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
________________________ ________________ ____________
Name Relationship Phone/Contact
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
10
DOCTORS
Name Type Address Phone Fax
===============================================================
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
Notes
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
--------------------------------------------------------------
|
