• Workdays missed due to condition:

  • How many work days?
  • Did you need a doctor's note?
  • Does this affect your pay?
  • Have you had to use sick time?
  • Have you had to use your vacation time?
  • Does missing work days affect the relationships you have with co-workers?

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• Lower productivity:

  • At Work:

    • Describe all tasks you now struggle with at work
    • Can you no longer complete these tasks?
    • Are these tasks required to be completed by your job?
    • Do you require help at work to complete these tasks?
    • By not completing these tasks, does it affect your pay?
    • By not completing these tasks, does it affect your relationships with your co-workers

  • At Home:

    • Describe all tasks you now struggle with at home
    • Can you no longer complete these tasks?
    • Do you require help to complete these tasks? Who helps you?
    • Do these tasks include things such as physical appearance? (Showering/ bathing/ grooming/ getting dressed)

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• Mental Health:

  • Does this condition/illness/pain affect your mental health?

    • How? Do you feel sad, or depressed?

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• Relationships with others:

  • Does this condition/illness/pain cause strained relationships with family, friends, or significant others? Explain how.

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• Mobility/Trouble Traveling:

  • Do you have difficulties traveling?
  • Do you drive or have others drive you?
  • It is difficult to sit in a car for long periods of time? How long?
  • Do you require mobility devices such as a cane, walker, or wheelchair?
  • Do you require medical devices when traveling such as an oxygen tank, CPAP machine or a respirator?
  • Do you have difficulties going up and down stairs?
  • Do you have difficulties standing for a period of time? How long?
  • Do you have difficulties sitting for a period of time? How long?
  • Do you have difficulties walking for a period of time? How long/far?
  • Do you have difficulties bending?
  • Do you have difficulties lifting items?

lower productivity (at work? at home? describe all task you struggle with or can no longer complete, did you use to be able to complete this task? do you require help to complete the task? Does this affect your pay? Does this affect your mental health? Does this affect your physical appearance such as washing and grooming yourself?) strained family relationships and friendships trouble traveling, etc.