DISABILITY ASSESSMENT ONLINE CHECK-IN FORM

DISABILITY ASSESSMENT QUESTIONAIRE
Name*

First NameLast Name
Date of Birth*

MonthDayYear
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?*

Loss of interest in activitiesDecreased energyFeelings of guiltGeneralized anxietyConsistencyAble to manage emotionsFlashbacks or intrusive thoughtsMood instabilitySubstance abuseObsessionsDelusionsOther
Which of the following basic activities of daily living are you unable to do for yourself without assistance?*

Bath for yourselfCook meals for yourselfMaintain your own residenceManage your funds in your best interestCare for childrenCare for petsPay billsOther
Which of the following are you unable to perform in a competitive work environment?*

Remember Work-Like ProceduresUnderstand Simple InstructionsCarry Out Simple InstructionsMaintain Attention for Two Hours at a TimeMaintain Regular Attendance and be PunctualSustain an Ordinary RoutineWork in Coordination with others without distractionMake Simple Work Related DecisionsComplete a Normal Work Day without InterruptionsPerform at a Consistent PaceAsk simple questions or request assistanceAccept instruction and appropriate criticism from supervisorsGet along with Coworkers without behavioral extremesRespond appropriately to changes in a routine work settingDeal with normal work stressBe aware of normal hazards and take precautionsUnderstand and remember detailed informationCarry out detailed instructionsSet realistic goals or make plans independently of othersDeal with stress of semiskilled workInteract with general publicMaintain socially appropriate behaviorAdhere to basic standards of neatness and cleanlinessTravel to unfamiliar placesUse public transportation
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

	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?
Should be Empty:

DISABILITY ASSESSMENT QUESTIONAIRE