Employment, ADL, and Recreation Information Patient Name File Number * Email Address Date Description of Work Condition's Effect On Job Performance No Effect Mild (painful can do) Mod (painful limited ability) Mod/Sev (limited duty) Sev (no limited duty) Sev (can't do limited duty) Daily Activities: Effects of Current Condition on Performance Bending No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Care-Infirm Family No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Carrying Groceries No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Change Positions (Sit-Stand) No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Climbing Stairs No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Driving No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Extended Computer Use No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Feeding No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Household Chores No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Kneeling No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Lift Children No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Lifting No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Pet Care No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Reading (Concentration) No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Self Care - Bathing No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Self Care - Dressing No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Self Care - Shaving No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Sexual Activities No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Sleep No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Static Sitting No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Static Standing No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Walking No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Yard Work No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Recreational Activity: Effects of Current Condition on Performance Fill in blank: _____________ No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Fill in blank: ______________ No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform Fill in blank: _________________ No Effect Mild Painful (Can do) Mod Painful (Limited) Sev Unable to Perform If you are human, leave this field blank.