How to Fill Out an Activities of Daily Living or Adult Function Questionnaire (SSA-3373-BK)

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Elizabeth D’Angelo

You may receive a form called Activities of Daily Living Questionnaire or Adult Function report.

Different states use slightly different forms.  Here is a blank copy of an example form.

Social Security sends out this form to learn more about your functioning and activities.

Social Security will usually send this form to you about month or two after you first apply for disability. They also sometimes send it to people who are already on disability during medical reviews.

Sometimes they will not send you the form, but instead will call and ask you the questions. If you’d like to be spared this fate, here’s How to Avoid Scary Phone Calls

If you get a form like this, it’s helpful if you can take time to really think about each question, but please don’t stress out about it. It is a common form and often does not have a major impact on your case. Your medical records will be much more important.

How To Fill Out an Adult Function Report

💮 Be honest with Social Security. It is best to just write what is actually true for you.

💮 Be honest with yourself. This is the biggest mistake many people make. It’s so important that you really admit exactly how bad things are and how much help you really need. It takes a lot of strength and courage to do this.

💮 Be brave. Don’t be shy. Write exactly how bad things are for you. If you feel really shy or embarrassed, please try to find a way to write it anyway. You can feel proud of yourself afterwards for doing something so hard!

💮 It is best to be honest and be consistent. Social Security may look to see that what you are saying to your doctors is the same thing you are writing on this form.

Getting Ready

You do not need to do these things. These are things some other readers have found helpful:

💮 Some people are helped a lot by asking a person they know well or a person who lives with them to review the form and point out any limitations they have seen.

💮 Some people also find it helpful to keep a symptom diary for a week, and note any time they are struggling with any activities. You will be surprised how long your list is! This list is for you, you don’t need to send it to Social Security. It is to help your notice and remember things.

💮 Some people make a blank copy first, in case they want to start again.

Having Trouble? 

💮 If filling out forms is difficult, you can ask a friend to help. If someone else completes the form for you, there is a place at the end of the form where the person who assisted you can write their name and contact information.

💮 Or you can contact the Social Security worker who sent you the form, and request to answer the questions by phone instead. This person’s name and contact information should be included.

💮 Or you can contact your local Social Security office. Let them know you need help and request an appointment with someone who can help you fill out these forms.

💮 In some cases, a lawyer or advocate may also help. However, some lawyers do not assist with function forms.

💮 Do not bring this form to your doctor. If you want your doctor to fill out a form for you, you can bring your doc an RFC form.

Describing Your Activities

💮 If you list any activities, it is a good idea to also mention if you have any limitations, any ways anyone assists you, or any way this activity is different for you now than it used to be. Learn more about: How To Describe Your Activities When You Apply for Disability

💮 Try to avoid saying something is “always” or “never” true or that you “can” or “cannot” do something, unless it really is always or never. If it is not always, then you can write “sometimes” “on my bad days….” or “when I am having symptoms…” or “most of the time…”

💮 Be aware of work-like activities. For example, cooking, cleaning and watching children are all things that could be a job. If you list any work-like activities, you can also make a brief note about any limitations with these activities, or anyone who assists you in any way.

💮 Include the impact of side effects. If your med side effects are making it hard to do certain activities, you can mention this. For example: If meds are making you tired, dizzy, in pain, or causing difficulty with focusing and concentrating.

💮 Great advice from attorney Scott Davis: “It is important to assume you are back working full time on a sustained basis (8 hours per day, 5 days per week) when answering questions about what you are capable of doing.”

“How Can I Make it PERFECT?”

Many people stress about this form because they think this is their “big chance” to explain themselves and prove they are disabled. It doesn’t really work that way.

This is just a standard form they use to learn a little more about how your illness limits you and to see if what you write about your limitations is similar to what your doctor writes.

No matter what you write, this form won’t “prove” you are disabled. Your medical records are far more important.

If you are struggling to complete the form, don’t worry about making it perfect. Just do the best you can with it and it’s OK if you need to cross something out or write “I don’t know.”

Remember, you are not applying for college. All the forms they get are from people who are disabled and too sick to work. They aren’t expecting it to be perfect!


Tips for Tricky Questions

“How does your illness limit your ability to work?”

💮 Write down if there are any medical reasons why you can’t work or why you are limited (for example, if you have problems with lifting, walking, sitting, standing, bending, grasping, focusing, remembering or concentrating).

💮 Don’t bother writing non-medical reasons. Social Security won’t consider non-medical reasons (for example, problems with transportation, child care, bad boss, slow economy, unemployment, etc)

💮 More ideas for how to answer the question: “Why Can’t You Work?”. They only give you room for a few sentences, so you can just put down a few basic ideas. At the bottom of this page, you can see how Petunia’s Answers The Question “Why Can’t You Work”

“Describe what you do from the moment you wake up to the moment you go to bed”

💮 They give you room to write just a few words. Luckily, many of us just lie down all day so there isn’t much to write. Please don’t stress out about the this question. Just list a few things you often do along with any ways you are limited or need assistance with those tasks. You can also mention how often or how many hours you lie down, take breaks, etc. At the bottom of this page is how Petunia’s Answers The Question “Describe Your Day”

“Yes or No?”

💮 There are a lot of “yes” and “no” boxes. You don’t have to check a box if neither answer is true for you. You can just write “sometimes” or “depends on symptoms” or “see below.” Never write something or check a box that is not true.

Do you take care of children/animals/other people?”

💮 If you take care of children, be honest about this. Please don’t forget to include if you need any assistance or if there are any things you are unable to do for your kids, or any limitations you have. Remember: They are not asking if you care about your kids. They are not asking if you are a good parent. They are asking about physical activities you do to take care of your kids. They are asking if you can hold down a job as a babysitter.

“Explain how your illness or injury affects your ability to dress, bathe, care for hair, shave, feed self, and use the toilet.”

💮 Good advice from SGB law office:  “Even if you are physically able to do these tasks, you still have problems in these areas if you don’t do them with normal regularity. For example:

  • Dressing: Do you stay in your pajamas during the day?
  • 
Bathing: Do you shower or bathe with the regularity that you had before you got sick. If not, you should note this!
  • Shopping: If you are able to go shopping but typically need someone with you while shopping, be sure to note this.”

Have you ever been fired from a job due to inability to get along with others?

💮 They are asking this because inability to get along with others is one of the limitations they consider for people applying for mental illness. If you answer yes to this question, they ask for the employer’s name. If you list an employer here, there is a chance they will contact the employer or send a form to ask questions about your ability to function and take care of yourself. This doesn’t happen often, and some employers just chose not to respond.

“How do you handle stress? Changes in routine? Fears? Authority figures?”

💮 These questions are all for people applying for mental health. Just answer honestly. If you don’t know the answer, it is OK to write “I don’t know.”

“Please list names and contact information for three people”

💮 The forms may ask you to list the names and contact information for people who can provide information about your life. You can list anyone who knows your life well – a friend, family member, or caregiver is often the best person.

💮 They will be contacting this person and asking them some very personal questions about you! Such as what kind of help you need to get dressed, eat, brush your teeth, or take a bath.

💮 The form may offer some friendly suggestions like “You can list your landlord or Social Worker”. Think carefully about this: Do you want your landlord to answer questions about how you brush your teeth?

💮 It is best to list someone who truly knows your daily life well and knows your limitations and the kind of care you need. If there is only one person who knows this, then you can just list that one person and write “No one else knows my daily life.”

💮 If there is truly no one who can provide information on your life, you can write this, but it is better if you can list at least one person. They may call or write your contact person. If your contact person does not wish to be called, just provide mailing address. See the link at the bottom of this page for more information on third party forms.


“I’m Stuck!”

If you get stuck, here’s four easy things you can do:

💮  Try writing the magic words. The magic words are: “When I am in pain…” or “When I am having severe symptoms….” or “When my symptoms are bad…” Many disability lawyers suggest using these words. Write down the magic words and then just finish the sentence. Roselyn applied for Paratransit, and here’s how she got approved by Using the Magic Words

💮 Try asking yourself this question: How is this activity different for me now then it was before I got sick? Then write down the answer.

💮  Try asking yourself this question: Does anyone help me in any way, even in a small way, to do this activity? Then write down the answer.

💮  If you are still stuck, here’s a list of more questions you can ask yourself about How To Describe Your Activities.

Try your best to answer as much as you can. If you get really stuck its OK to leave some questions blank or write “N/A” or “I don’t know.” A blank answer is better than writing something untrue. Just do the best you can. Many times people with very severe disabilities are unable to complete these forms and send back forms where some questions are blank.

Once again, if they ask a question and you don’t know the answer, it’s OK to write that you don’t know.

“How Much Should I Write?”

There are different opinions by lawyers and advocates about how to fill out this form. Some people say be detailed about your condition, tell them all your struggles, and attach extra pages.

Other lawyers say be brief and clear, never attach extra pages, and be careful not to write anything that could cause confusion, be misunderstood, or hurt your case.

You should do what you feel comfortable with.

“Should I Include Attachments?”

💮  If you have any medical tests results or medical records you have not yet sent to Social Security, you can enclose them with these forms. Sometimes submitting things all together at once increases the chances that nothing gets lost or put in the wrong file.

💮  It is not necessary to send long letters telling Social Security your life story and all your struggles. These may not be read, and there are many more important and helpful ways you could be spending your energy to help your application.

💮  On the other hand, if you are able to put together an outline of your medical records and history, this can be a huge help. Here’s a few great examples: How To Make a Medical Outline to Help Your Disability Case. Holly attached a great medical synopsis to her Adult Function Form: Holly’s Fantastic Medical Synopsis for Disability

💮  If you want to create an outline or synopsis but don’t have time, you don’t have to send it right now. You can submit more materials any time. Of course, sooner is always better.


Tips from Rose

Rose is a contributor to this site with some super smart ideas for disability applications. Here’s a few of her tips for adult function forms:

💮 Illustrate a picture for SSA to see what your life is like. Think about your worst day. Avoid using the words “always” or “never,” because it can create a problem with credibility. “Typically” and “usually” are good words to use.

💮  Discuss what modifications you use. For example, if the question is, “Do you shower?” The answer might not be “yes” or “no”. The answer might be “Yes, but I use a shower bench and need to lay down for X time to recover afterwards” That answer gives a different picture than just saying “yes”.

💮  You can use the coversheet that came with the forms to submit additional medical records etc as well.

💮 If you are unable to complete the packet by the deadline, call the phone number in the packet and request an extension. One extension should be pretty much automatically be granted, but you have to request it. If you just turn in the packet late, then they could make a decision without it & you can get denied for not responding properly.

💮 And make sure you keep a copy of everything you submit!


What’s Next?

💮  Whenever sending anything, it’s always a good idea to contact the person handling your case and make sure that it was received and placed in your file. Make sure to talk directly to the person handling your case (usually called “Disability Examiner”). Their name and contact information should appear on the forms you were sent. Or you can call and ask.

💮  Next up, they may send a similar form to your contact person to answer questions about you. Here’s how to handle an Adult Function Third Party Report (SSA-3380-BK)

💮  If this is a new application, Social Security may also send you a Work History Form. How to fill Out a Work History Report (SSA-3639-BK)

💮  If you are already approved and being reviewed, learn more about How to Complete a Continuing Disability Review

💮  If you are still applying, take a look here: How to Greatly, Greatly (Greatly!) Improve Your Disability Application


Updated April 2018. Please comment below with stories, ideas, questions or suggestions. Please let us know if any links on this page stop working. If you found this page helpful, please share it with others by pressing one of these magic little buttons: 

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