Follow the steps to fill out the questionnaire effectively.

1. Click the ‘Get Form’ button to obtain the questionnaire and open it in your preferred editing tool.
2. Begin by providing your information, including your name and case number located at the top of the form.
3. Next, respond to the first question about your current living situation. You will need to circle one of the options provided: house, apartment, boarding home, nursing home, or other. If you select 'other,' be prepared to explain.
4. Answer the question regarding whom you live with by circling one of the options: alone, with family, with friends, board & care, or other. Again, provide an explanation if you choose 'other.'
5. Describe how your symptoms affect your daily work activities in detail. Be specific in explaining how conditions such as pain or fatigue impede your work routine.
6. Detail your average daily activities in the next section. Describe what you do each day and how these activities impact your well-being.
7. Provide information about your walking ability. State how far you can walk, the time taken for this distance, and how you feel afterward.
8. Answer whether you can climb stairs and specify the number of flights. Explain how this affects you if the answer is 'yes.'
9. Indicate what items you can lift and how frequently you do so.
10. State what items you can carry, including how far and how often.
11. Clarify if you clean your own living area. If 'yes,' list the chores you complete and the time it takes.
12. Indicate whether you drive a car, mentioning if it is manual or automatic, and detail how far you can drive at one time.
13. Respond to whether you perform any car maintenance tasks or yard work, along with descriptions of how these activities affect you.
14. State if there were any differences in your ability to perform chores before and after your disability began.
15. Explain any difficulties you face in completing household tasks and how long you can work before needing to stop.
16. Record your sleeping hours and if you require daily rest periods, indicating how often and for how long.
17. List any medications you take, along with their names, dosages, and frequency.
18. Detail any mobility aids you use, such as splints or canes, explaining their purpose and frequency of use.
19. Lastly, provide any additional information about your condition in the space provided.
20. Be sure to sign and date the form at the end, ensuring that your phone number is also provided.
21. Once completed, review your responses for accuracy and completeness. You can then save your changes, download, print, or share the form as needed.

Start filling out your documents online today to ensure a smooth process.