Client's name:
Disabilities / Functional Limitations
Stability:
1. Is the disabling condition:
improving,
deteriorating, or
stable?
2. Do the conditions change so that a person may have to stay away from work or have reduced performance?
yes /
no.
3. What kinds of activities or environments irritate the condition?
Treatment:
4. What treatment has the client received - kind, when, where, frequency, by whom, current and future status?
5. Is the treatment schedule followed? For example, if a person is a diabetic, is he following his diet and checking his blood sugars regularly?
6. What are the assistive devices that he needs to use to walk or help with daily activities?
7. If medications are necessary, what is the effect of the medicine?
Limitations in Function:
8. How is the person limited by his disability?
9. What corrections have been made to improve his function?
10. How severe are his physical functions?
11. How well does the person compensate for his limitations - does he strive to improve his physical function or does he sit at home during the day?
Attitudes
12. How does the person react to the disability and its limitations?
13. Does he have personal adjustment problems with the disability that need to be treated? If so, how?
14. Does the person recognize his problems and the need to solve them?
yes /
no.
Family Stability
15. What is the relationship between the person and his family?
16. Will the family be supportive of the person and make an effort to find work for him?
yes /
no.
17. Do they understand what you are trying to do and will they cooperate?
yes /
no.
18. Will the family be willing to make changes so that the person can work?
yes /
no.
19. Is there a history of problems with the law?
yes /
no.
20. What is the quality of the relationship between husband and wife?
21. Who are the people in the household?
Personal/Social
22. What incentives are there for a person to work?
23. What disincentives are there for working - i.e., is it better for a person to stay home for some reason than to work?
24. How well does the person get along with others?
25. Is the person liked by family, friends, and neighbors?
yes /
no.
26. What does the person do in his free time?
Employment
Work Experience
27. What kinds of jobs has the person done, how long did he work at each job, and why did he leave?
Stability
28. Is there a pattern of a stable work history?
yes /
no.
29. What are the reasons for unemployment if any?
Assets
30. What job skills has the person acquired - does he have specialized knowledge in a certain job? What level of knowledge does he have for his particular type of job?
31. What are his past achievements in his job? Was he punctual and dependable?
32. How motivated is this person to do work?
33. Has his social adjustment been good so that his work adjustment is also good?
yes /
no.
Potential
34. Are there jobs for this person to do in the local area?
yes /
no.
35. Is there any job available for him at his former employment?
yes /
no.
Education and Training
36. What was the highest level of education attained?
37. What kinds of grades did he have?
38. What subjects did he like and dislike?
39. What other training has he had: technical school, training in the army, college or university?
40. What interest does the person have in further vocational preparation?
41. Would he like further education for a change in profession?
yes /
no.
Finances
Financial Means
42. What are the family's financial resources: who works to provide for this family?
43. What is the current income and how does the family live from that income?
44. What are the financial needs and acceptable income?
Personality and Habits
45. What was the person like before the disability?
enthusiastic,
energetic,
depressed,
all right.
46. What type of temperament does he have?
easy-going,
nervous,
easily upset,
normal.
47. How would others describe him?
48. What are his personal habits? Does he like to get up early, late? Does he pay his bills on time? Does he smoke? Does he drink to excess?
49. What attitudes does he have about life?
50. Other observations by the interviewer:
Now you can click on the "Send" button below, Then you can copy-and-paste this information from your email program into your client's computer file. Or you can go to the top of this form and print it, then file the paper copy.