DISABILITY ASSESSMENT ONLINE CHECK-IN FORM

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Area CodePhone Number

When where you first unable to work?

Which long-term psychiatric symptoms stop you from working?

Which of the following basic activities of daily living are you unable to do for yourself without assistance?

Which of the following are you unable to perform in a competitive work environment?

Have you had any recent hospital or partial hospitalizations for the mental conditions which effect your ability to work? If so describe below…

Which dates have you visited this office for the condition associated with the disability?

What other providers have you seen for the condition associated with your disability?

If you are currently working, what is your job description and what duties do you perform?

Which of those duties are you impaired from doing from mental conditions?

Are you able to aggressively explore treatments to get back to work including hospitalization, partial hospitalization, and weekly psychotherapy and medication visits? If not, please describe what you are willing/able to do to get back to work as soon as possible including the above options:

What other factors impair your ability to return to work in some fashion?

What accommodations could assist you in returning to work?

The next assessment is a WHODAS 2.0 which is a standardized self-assessment of disability. Answer each of the following questions regarding how much difficulty did you have in the following areas using the following scale from 1-5.

(1)= no difficulty

(2)= mild difficulty

(3)= moderate difficulty

(4)= severe difficulty

(5)= extreme difficulty or unable to accomplish at all

Rows	1	2	3	4	5
Standing for long periods such as 30 minutes?
Taking care of your household responsibilities?
Learning a new task, for example, learning how to get to a new place?
How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?
How much have you been emotionally affected by your health problems?
Concentrating on doing something for ten minutes?
Walking a long distance such as a kilometre [or equivalent]?
Washing your whole body?
Getting dressed?
Dealing with people you do not know?
Maintaining a friendship?
Your day-to-day work?

Overall, in the past 30 days, how many days were thesedifficulties present?

In the past 30 days, for how many days were you totally unableto carry out your usual activities or work because of any healthcondition?

In the past 30 days, not counting the days that you were totallyunable, for how many days did you cut back or reduce yourusual activities or work because of any health condition?

DISABILITY ASSESSMENT QUESTIONAIRE