Long-Term Disability Questionnaire
Please complete this questionnaire to help us understand the impact of your long-term disability on your daily life and work.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the primary cause of your disability?
*
Please Select
Injury
Illness
Congenital condition
Other
When did your disability begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate the extent to which your disability affects the following daily activities:
*
Rows
No Difficulty
Some Difficulty
Unable to Perform
Walking
1
2
3
Standing
4
5
6
Sitting
7
8
9
Lifting/Carrying
10
11
12
Personal Care (dressing, bathing)
13
14
15
Preparing Meals
16
17
18
Household Tasks
19
20
21
Are you currently able to work?
*
Yes, full-time
Yes, part-time
No
Please rate the severity of your symptoms on average over the past week.
*
1
2
3
4
5
6
7
8
9
10
List any assistive devices or aids you use (e.g., wheelchair, cane, hearing aid).
Please provide any additional information about your condition or limitations.
Signature
*
Submit
Submit
Should be Empty: