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Function Report

Maps to SSA-3373. Describes how your conditions affect daily life. Save as you go — long form, take breaks. The longer and more specific, the better.

A. Information about you

Living situation (who do you live with, what's your housing?) A typical day from waking up to going to bed

B. Personal care

For each: do you need help, take longer than before, or can't do it at all?

Dressing Bathing Hair care Shaving / makeup Feeding yourself Using the toilet

C. Daily living

Meal preparation Housework / yard work Getting around (driving, transit, walking) Shopping Handling money / bills

D. Hobbies & social

Hobbies and interests (and how they've changed) Social activities

E. Physical & mental abilities

Lifting (how much, how often, what hurts after) Standing (how long, what limits you) Walking (distance, speed, rest needed) Sitting (how long before you have to move) Climbing stairs / ladders Kneeling, squatting, crouching Concentration (how long can you focus) Memory Following instructions (written, spoken) Handling stress / changes in routine

F. Overall impact

How your conditions affect your life — anything else SSA should know

Print full report Official SSA-3373 ↗