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Activities of Daily Living (ADLs)
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Patient Name
First
Last
Date
Date Format: MM slash DD slash YYYY
ACTIVITIES OF DAILY LIVING (ADL’S)
INSTRUCTIONS
Please complete the following questionnaire as it relates to how your injury(s) have affected your performance of daily living and work/school activities. For each area (e.g. Work, School, Domestic Activities, etc.), there is a list of day-to-day activities which are often difficult to perform as a result of injury (e.g. Lifting, Bending, Laundry, etc.). Please do the following:
1) If ANY of the activities listed were difficult for you AT ANY TIME since your pain first began, write the body area that caused the difficulty in the blank next to the activity (if you have multiple injured body areas, write all areas that bother you during that activity).
a. If it is a thinking or emotional problem that causes the difficulty, such as fear, anxiety, irritability, forgetfulness, or poor concentration, write “Brain” as the injured area in the blank.
2) Click on the appropriate box or boxes (all that apply) designating the reason(s) for the difficulty, and include activities even if you can do them, but you can’t do them for as long as you want or need to.
3) Note how long this difficulty(s) has been present (Duration) and whether you still experience the difficulty (if you checked multiple activities in a section, note the duration of the one which bothered you the longest). Check the box to indicate if the difficulty is ongoing.
Work Activities
Lifting (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Bending (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Sitting (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Walking (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Carrying (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Reaching (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Kneeling (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Reading (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Mental Tasks (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Computer Use (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Managing People (Work)
Reason for the difficulty
Pain
Irritability
Fatigue
Concentration
Anxiety
Memory
Interacting With People (Work)
Reason for the difficulty
Pain
Irritability
Disinterest
Concentration
Anxiety
Memory
Meeting Deadlines (Work)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Other (Work)
Name of Activity
List difficulties
Please mark the boxes below if
difficulties with any of the following
have caused problems for you at work
since the accident
(only if the difficulty was not present before the accident):
These difficulties have caused me problems at work
Memory
Easily Distracted
Feeling Depressed
Problem Solving
Anxiety
Worrying / Nervousness
Making Decisions
Irritability / Outbursts
Sleepiness
Duration in Months (Work)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Work)
Yes
No
Constant since pain began
Studies / School
Sitting (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Walking (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Carrying (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Writing (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Reading (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Studying (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Taking Exams (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Computer Use (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Attending Class (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Meeting Deadlines (Studies / School)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Other (Studies / School)
Name of Activity
List difficulties
Please mark the boxes below if
difficulties with any of the following
have caused problems for you at school
since the accident
(only if the difficulty was not present before the accident):
These difficulties have caused me problems at school
Memory
Easily Distracted
Feeling Depressed
Problem Solving
Anxiety
Worrying / Nervousness
Making Decisions
Irritability / Outbursts
Sleepiness
Duration in Months (Studies / School)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Studies / School)
Yes
No
Constant since pain began
Domestic Activities
Laundry (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Cleaning (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Vacuuming (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Dishwashing (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Preparing Meals (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Taking care of kids (Domestic)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Other (Domestic)
Name of Activity
List difficulties
Please mark the boxes below if
difficulties with any of the following
have caused problems with domestic activities
since the accident
(only if the difficulty was not present before the accident):
These difficulties have caused me problems with domestic activities
Memory
Easily Distracted
Feeling Depressed
Problem Solving
Anxiety
Worrying / Nervousness
Making Decisions
Irritability / Outbursts
Sleepiness
Duration in Months (Domestic)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Domestic)
Yes
No
Constant since pain began
Household Activities
Gardening (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Yard work (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Landscaping (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Car Washing (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Mowing Lawn (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Driving (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Taking out trash (Household)
Reason for the difficulty
Pain
Restricted Movement
Weakness
Fatigue
Concentration
Other (Household)
Name of Activity
List difficulties
Please mark the boxes below if
difficulties with any of the following
have caused problems with household activities
since the accident
(only if the difficulty was not present before the accident):
These difficulties have caused me problems with household activities
Memory
Easily Distracted
Feeling Depressed
Problem Solving
Anxiety
Worrying / Nervousness
Making Decisions
Irritability / Outbursts
Sleepiness
Duration in Months (Household)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Household)
Yes
No
Constant since pain began
LOSS OF ENJOYMENT OF ACTIVITIES SUMMARY
INSTRUCTIONS
Complete the following questionnaire as it relates to the
activities
(work related or otherwise)
you enjoyed before your pain began but are
currently not enjoying
(
or not enjoying to the extent that you previously did
)
as a result of your injury(s)
. Click the box next to the reason for your loss of enjoyment for ALL activities that apply. Also click the box next to any statements which are true for you.
Work
Reason for the loss of enjoyment (Work)
Loss of status within organization
Loss of opportunities with the organization
Difficulty performing work duties
Difficulty concentrating / focusing at work
Reduced quality of work
Don’t look forward to working anymore
Boss has commented on decreased performance
Making less money than before the accident
Increased number of mistakes
More difficulties
Other
Reason for the loss of enjoyment – Other (Work)
Write your notes here.
Duration in Months (Loss Enjoyment – Work)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Work)
Yes
No
Constant since pain began
Studies / School
Reason for the loss of enjoyment (Studies / School)
Difficulty studying as long as desired or as much as needed
Difficulty traversing campus, sitting in class, or carrying books
Grades have decreased
Had to take fewer classes
Difficulty concentrating/focusing in class or while studying
Reduced quality of assignments
Difficulty turning in assignments on time
Don’t learn as quickly or easily as before the accident
Had to take semester off or drop out
Other
Reason for the loss of enjoyment – Other (Work)
Write your notes here.
Duration in Months (Loss Enjoyment – Studies / Schools)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Studies / Schools)
Yes
No
Constant since pain began
Domestic Duties
Reason for the loss of enjoyment (Decorating)
Painful
House doesn’t look as nice
Reason for the loss of enjoyment (Cleaning)
Painful
House doesn’t look as nice
House isn’t as clean / neat
Reason for the loss of enjoyment (Taking care of kids)
Painful
Can’t do same activities
Relationship with kids has suffered
Reason for the loss of enjoyment (Preparing Meals)
Painful
Takes me much longer to cook
Make more mistakes
Reason for the loss of enjoyment (Sex)
Painful
Decreased desire
Can’t perform as before
Reason for the loss of enjoyment – Other (Domestic Duties)
Your reason…
Describe the pain and reason for loss of enjoyment
Please mark the boxes next to any statements below which are true for you since the accident:
I have had to get others to help me prepare meals
I have had to hire someone to clean the house since the accident
I have had to hire someone to help with the kids since the accident
Relationship with my significant other has suffered due to my domestic difficulties
Duration in Months (Loss Enjoyment – Domestic Duties)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Domestic Duties)
Yes
No
Constant since pain began
Household Duties
Reason for the loss of enjoyment [Yard Work]
Painful
Yard doesn’t look as nice
Takes much longer to finish
Reason for the loss of enjoyment [Shopping]
Painful
Pain prevents me from finishing
I have to rush due to the pain
Reason for the loss of enjoyment [Driving]
Painful
Anxiety / Worry / Nervousness
Reason for the loss of enjoyment [Mowing Lawn]
Painful
Yard doesn’t look as nice
Make more mistakes
Reason for the loss of enjoyment [Landscaping]
Painful
Yard doesn’t look as nice
Reason for the loss of enjoyment [Gardening]
Painful
Garden doesn’t look as nice
Reason for the loss of enjoyment – Other [Household Duties]
Your reason…
Describe the pain and reason for loss of enjoyment
Please mark the boxes next to any statements below which are true for you since the accident:
I have had to hire someone to take care of the yard
Relationship with my significant other has suffered due to my household difficulties
Duration in Months (Loss Enjoyment – Household Duties)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Household Duties)
Yes
No
Constant since pain began
Hobbies
Aerobic Exercise – Reason for the loss of enjoyment
Painful
Less endurance now
Can’t do it anymore
No fun anymore
Hiking – Reason for the loss of enjoyment
Painful
Less endurance now
Can’t do it anymore
No fun anymore
Weight Training – Reason for the loss of enjoyment
Painful
Weaker now
Can’t do it anymore
No fun anymore
Bowling – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Playing Cards – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Arts / Crafts – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Sewing / Knitting – Reason for the loss of enjoyment
Painful
Not as skilled anymore
Can’t do it anymore
No fun anymore
Water Sports – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Playing Music – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Yoga / Pilates – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Traveling – Reason for the loss of enjoyment
Painful
Can’t go where I want
Can’t do it anymore
No fun anymore
Martial Arts – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Athletics – Reason for the loss of enjoyment
Painful
Not as good anymore
Can’t do it anymore
No fun anymore
Duration in Months (Loss Enjoyment – Hobbies)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Hobbies)
Yes
No
Constant since pain began
Sports
Name of Sport:
Reason for Loss of Enjoyment for Your Sport
Painful
Not as good anymore
Can’t do it anymore
Pre-accident level of participation
Socially
Competitively
Professionally
Post-accident level of participation
Socially
Competitively
Professionally
Can’t Participate
Duration in Months (Loss Enjoyment – Sports)
Please enter a number from
1
to
24
.
Write the number of months you had difficulties.
– OR –
Difficulty(s) ongoing (Loss Enjoyment – Sports)
Yes
No
Constant since pain began
Consent
*
I agree to the following.
By proceeding with the submission of this form, you consent that all the information provided has been filled out honestly and to the best of your ability. You understand that the details you’ve provided will be utilized to construct your legal case. It is imperative to ensure accuracy and completeness in the information provided, as it will play a crucial role in representing your interests effectively. If you have any concerns or require clarification regarding the form or its contents, please do not hesitate to seek assistance. Your cooperation in this matter is greatly appreciated.
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