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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.

Daily Activities Worksheet


One of the areas Social Security looks at when determining whether you are "disabled" for purposes of Social Security Disability Insurance (SSDI) is how your health condition(s) impact daily living.  This worksheet is geared to help you pull together the facts.

This Daily Activities Worksheet asks for information about your impairment that your doctor needs for an accurate report, and Social Security needs for understanding the impact of your illness/ injury.

Typical month: How many good, fair, and bad days do you have during an average month?

  • Good days: ____
  • Fair days:   ____.
  • Poor days:  ____
  • Days you feel too poorly to:
    • Leave bed: _____
    • Go out:      _____

What is a good day? ____________________________________________________________________________________________


What is a fair day? (try to be as specific as you can: for example, I am too tired to cook, and I usually cook (breakfast, lunch, dinner) _______


What is a poor day? (please be specific) _____________________________________________________________________________


Progression: Have you noticed a progression - for example that you have been able to less or more in the past 6 months? If so, please describe:



Caring For Yourself    Consider whether your health condition(s) make it difficult to care for any of the following needs. If it does, please provide examples

  • Activities
    • Doing things on time  Y/N Example(s): ___________________________________________________________________________________
    • Finishing things on time  Y/N Example(s): ___________________________________________________________________________________
  • Bathing  Y/N Example(s): ___________________________________________________________________________________
  • Caring for hair  Y/N Example(s): _____________________________________________________________________________
  • Decisions (making)  Y/N Example(s): ___________________________________________________________________________________
  • Doing chores Y/N Example(s): ___________________________________________________________________________
  • Dressing  Y/N Example(s): ___________________________________________________________________________________
  • Driving or using public transportation Y/N Examples: _______________________________________________________________
  • Eating  Y/N Example(s): ___________________________________________________________________________________
  • Hair care Y/N Example(s): ___________________________________________________________________________________
  • Hobbies: Y/N Example(s): ___________________________________________________________________________________
  • Information (keeping informed)   Y/N Example(s): ____________________________________________________________________________
  • Instructions (following)  Y/N Example(s): ___________________________________________________________________________________
  • Meals (breakfast, lunch, dinner)
    • Preparing   Y/N Example(s): __________________________________________________________________________________________
    • Eating  Y/N Example(s): _____________________________________________________________________________________________
    • Feeding self Y/N Example(s): _________________________________________________________________________________________
  • Medications - taking as directed  Y/N Example(s): ___________________________________________________________________________________
  • Objects
    • Holding on to  Y/N Example(s): ___________________________________________________________________________________
    • Using telephone  Y/N Example(s): ___________________________________________________________________________________
    • Using computer/tablet   Y/N Example(s): ___________________________________________________________________________________
  • People
    • Caring for others  Y/N Example(s): ___________________________________________________________________________________
    • Visitng people      Y/N Example(s): ___________________________________________________________________________________
    • Group activities    Y/N Example(s): ___________________________________________________________________________________
    • Religious gatherings (e.g. services)   Y/N Example(s):_______________________________________________________ _____________
    • Socializing            Y/N Example(s): ___________________________________________________________________________________
  • Personal business/finance    Y/N Example(s): ___________________________________________________________________________________
  • Recreation
    • Exercise   Y/N Example(s): ___________________________________________________________________________________
    • Sports       Y/N Example(s): ___________________________________________________________________________________
  • Shaving  Y/N Example(s): ___________________________________________________________________________________
  • Shopping Y/N Example(s): ___________________________________________________________________________________
  • Sleeping  Y/N Example(s): ___________________________________________________________________________________
  • Stairs - using  Y/N Example(s): ___________________________________________________________________________________
  • Toilet-:
    • Using  Y/N Example(s): ___________________________________________________________________________________
    • Getting to  Y/N Example(s): ___________________________________________________________________________________
  • Other: (please describe) ___________________________________________________________________________________________  

   Work Related Activities:- which of the following are affected by your health condition(s)? Provide examples

  • Adjusting to changes
  • Balance - keeping your balance
  • Bending over
  • Carrying
  • Carrying out instructions
  • Crawling
  • Crouching
  • Finishing what you start
  • Getting along with:
    • People who annoy you
    • People you work with
    • People who supervise you
  • Grasping, handling, fingering
  • Hearing
  • Lifting
  • Pushing pulling with:
    • Hands
    • Legs
  • Reaching: 
    • Down
    • Out
    • Up
  • Remembering 
  • Seeing
  • Sitting
  • Speaking
  • Standing
  • Traveling (driving or using public transportation)
  • Understanding
  • Working productively consistently

Other work related activities

 Other activites (be specific) _______________________________________________________________________________

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