Disability Tax Credit
About Us
Testimonials
- Case Studies
Contact Us
Request Assessment

Disability Tax Credit
About Us
Testimonials
- Case Studies
Contact Us

Disability Tax Credit
About Us
Testimonials
- Case Studies
Contact Us

Disability Tax Credit
About Us
Testimonials
- Case Studies
Contact Us

Disability Tax Credit
About Us
Testimonials
- Case Studies
Contact Us

Disability tax credit calculator badge

FREE ASSESSMENT

Home » Activities of daily living – functions assessment

Activities of daily living – functions assessment

FREE ASSESSMENT

February 20, 2021 by dccinc

ACTIVITIES OF DAILY LIVING - FUNCTIONS ASSESSMENT

Filling out the following form will help us better understand your situation as we formulate your CPP Disability case

Step 1 of 10 - Medical History

10%

Name*
First Last
Email*
Date of Birth*
MM slash DD slash YYYY
MEDICAL HISTORY
Please include all physicians, specialists, and medical professionals that you continue to see regarding your medical conditions
Physician’s name
Name of 1st Specialist
Name of 2nd Specialist
Name of Chiropractor
Name of Physiotherapist
Name of Psychologist/Therapist
Name of Nurse Practitioner
Have you ever been hospitalized?
- Yes
- No
List all hospitalizations
Please list all hospitalizations within the last three years, please attach the dates and how long you were hospitalized
Treatments and therapy
Please list any tests, counseling, therapy, or treatments regarding your medical condition

Continence/Toilet
Please explain all challenges and restrictions regarding toileting per day.
Continence/Toilet
Please check ALL that apply
- Cares for self at toilet completely, no incontinence
- Needs to be reminded or needs help in cleaning self, or has accidents
- Requires incontinence pads or diapers
- Accidents in the workplace or in public places
- Constant leakage or diarrhea
- Anal fissures
- Anal fistula or abscess
- Soiling or wetting while asleep on a regular basis
- Soiling or wetting while awake on a regular basis
- No control of bowels or bladder
- Mucous or blood discharge episodes
- Substantial pain or discomfort
How many times are you visiting the restroom per day?
How much time do you spend in the restroom per visit?
Is there anything you'd like to add regarding continence/toilet?

Feeding
Please explain all challenges and restrictions regarding feeding
Feeding
Please select all that apply
- Eats without assistance
- Eats with minor assistance at mealtimes and/or with special food preparation
- Feeds self with moderate assistance and is untidy
- Requires extensive assistance for all meals
- Does not feed self at all and resists efforts of others to help
- Unable to cut meat or vegetables yourself
- Unable to open a new milk carton
- Difficulty eating a bowl of spaghetti and meat balls
- Arthritic or Osteoarthritic pain in hands
- Carpel Tunnel Syndrome in hands/arms
How long does it take (in minutes) to eat an average-sized meal?
Please enter a number from 0 to 60.
Is there anything you'd like to add regarding feeding?

Dressing
Please explain all challenges and restrictions regarding dressing
Dressing
- Dresses, undresses, and selects clothes from own wardrobe
- Dresses and undresses with minor assistance
- Needs moderate assistance in dressing or selection of clothes
- Needs major assistance with dressing, but cooperates with assistant
- Needs to be dressed by another person for certain items (list them below)
- Long periods of time utilized on a daily basis to dress
- Required to sit down in order to put on shoes and pants
- Requires another person to put on undergarments
How long does it take you to get dressed in the morning? (in minutes)
How long does it take you to get dressed in the evening? (in minutes)
Is there anything you'd like to add regarding dressing?

Walking/ Ambulation
Please explain all challenges and restrictions regarding walking and ambulation
Walking/Ambulation
- Experiences severe pains when walking down the street
- Walks within residence or about one block distance
- Cannot propel self without help
- Bedridden for significant periods of time
- Unable to walk up steps/stairs
- Requires significantly long periods of time to ambulate/walk a short distance
- Limps due to pain related impairment
- When walking around a mall, struggles to keep up with others
- Unable to stand for long periods of time – limited standing tolerances
Walks/ambulates with assistance
Please select all that apply
- Select All
- Another person
- Cane
- Wheelchair- gets in/out without help
- Railing
- Walker
- Wheelchair- needs help to get in/out
How long does it take you (in minutes) to walk one city block
How long does it take you (in minutes) to walk around a mall
Is there anything you'd like to add regarding Walking/Ambulation?

Assistive Devices
Please check off all assistive devices used on a daily basis or at least 90% of the time
Assistive Devices
- Wheelchair
- Cane
- Crutches
- Scooter
- Walker
- Orthotic devices
- Prosthetic devices
- Raised toilet seat
- Grab bars
- Bath seat
- Third Choice
- Railway for stairs
Is there anything you'd like to add regarding assistive devices?

Activities of Daily Living Checklist
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Personal Care
Bathing
- Can do
- Can do partially
- Can do with help
- Can not do at all
Grooming
- Can do
- Can do partially
- Can do with help
- Can not do at all
Dressing/Undressing
- Can do
- Can do partially
- Can do with help
- Can not do at all
Toileting
- Can do
- Can do partially
- Can do with help
- Can not do at all
Mobility
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Walking
- Can do
- Can do partially
- Can do with help
- Can not do at all
Transferring
- Can do
- Can do partially
- Can do with help
- Can not do at all
Climbing Stairs
- Can do
- Can do partially
- Can do with help
- Can not do at all
Driving
- Can do
- Can do partially
- Can do with help
- Can not do at all
Riding in Car
- Can do
- Can do partially
- Can do with help
- Can not do at all
Public Transportation
- Can do
- Can do partially
- Can do with help
- Can not do at all
Sitting
- Can do
- Can do partially
- Can do with help
- Can not do at all
Standing
- Can do
- Can do partially
- Can do with help
- Can not do at all
Reaching
- Can do
- Can do partially
- Can do with help
- Can not do at all
Shopping
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Groceries
- Can do
- Can do partially
- Can do with help
- Can not do at all
Meals
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Making Meals
- Can do
- Can do partially
- Can do with help
- Can not do at all
Cooking
- Can do
- Can do partially
- Can do with help
- Can not do at all
Housekeeping
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Vacuuming
- Can do
- Can do partially
- Can do with help
- Can not do at all
Sweeping
- Can do
- Can do partially
- Can do with help
- Can not do at all
Bed Making
- Can do
- Can do partially
- Can do with help
- Can not do at all
Garbage Removal
- Can do
- Can do partially
- Can do with help
- Can not do at all
Laundry
- Can do
- Can do partially
- Can do with help
- Can not do at all
Home Maintenance
Please select one option for each category below that best describes your ability to perform that task when your medical condition(s) is at its worst
Gardening
- Can do
- Can do partially
- Can do with help
- Can not do at all
Grass Cutting
- Can do
- Can do partially
- Can do with help
- Can not do at all
Snow Shoveling
- Can do
- Can do partially
- Can do with help
- Can not do at all

Medication Information
Do you take any medication?*
- Yes
- No
Medication Name
Dose
Frequency
Start Date
Using Now?
Side Effects
Do you take any other medications?
- Yes
- No
Medication Name
Dose
Frequency
Start Date
Using now?
Side effects
Do you take any other medications?*
- Yes
- No
Medication name
Dose
Frequency
Start date
Using now?
Side effects

Pain Related Problems
Please complete either the pain related section or the psychological related section if applicable or Please complete both sections if applicable
Chronic pain or fibromyalgia
- Moderate pain that does not go away
- Severe pain that does not go away
Pain that may be described as:
Please select all that apply
- Shooting
- Burning
- Aching
- Discomfort
- Soreness
- Tightness or stiffness
Pain scale from 0-10
Please enter a number from 0 to 10.
Is your pain
- Constant
- Comes and goes
Anything else you'd like to add?
Psychological problems
Psychological
Please select all that apply
- Low mood, feelings of guilt/worthlessness, loss of interest
- Agitated, irritable, short tempered
- Anxiety, excessive worry, panic attacks
Sleep disturbances
- Can’t fall asleep
- Can’t stay asleep
How many hours do you sleep for?
Please enter a number from 1 to 24.
How many times do you wake up every night?
Please enter a number from 1 to 10.
Cognitive difficulties
Please select all that apply
- Short term memory
- Long term memory
- Speech, word-finding
- Attention, concentration
- Forgetfulness
- Following instructions
Depression
Please select all that apply
- Hopelessness
- Low motivation
- Suicidality
- Low mood
Anxiety
Please select all that apply
- Low motivation
- Forgetfulness
- Low mood
- Hypervigilance
Panic Attacks
Please select all that apply
- Elevated heart rate/heart pounding
- Difficulty breathing
- Sweatiness
- Feeling like losing control
Anything else you'd like to add?

Employment history
Information regarding the position of the job that you left
What was the last title or position of the job you left
Type of work done
- Manual labour
- Administrative
- Sedentary
- Modified duties
- Light duties
Describe the preceding two years before you stopped working
Did you try alternative types of work, light duties, did you have many sick days? Any short-term disability leaves? Was your employer accommodating?

DISABILITY CREDIT CANADA INC.
ADDRESS: 3701 Chesswood Drive, #208 Toronto, Ontario M3J 2P6, Canada
TOLL-FREE: 1-844-800-6020
FAX: 647-846-7542

DISABILITY RESOURCES

DCCI Scholarship for Canadian Students with Disabilities

Disability Tax Credit Resources

The Disability Tax Credit Resource Guide (Updated February 2026)
The Definitive Guide To Child Disability Tax Credit
Disability Tax Credit Calculator
Disability Tax Credit Frequently Asked Questions
Disability Tax Credit Form – T2201
Disability Tax Credit Application Process
Disability Tax Credit Eligible Conditions Information

Long Term Disability Benefits & WSIB Resources

WSIB Claims and Appeals
Long Term Disability Claims and Appeals
Long Term Disability Denied
Long Term Disability Eligibility

CPP Disability Resources

The Ultimate CPP Disability Guide
CPP Disability Benefits Application Guide
Reasons CPP Disability Applications Are Denied
CPP Disability Denial and Appeal Overview
How To Write a CPP Disability Appeal Letter
CPP Disability Request For Reconsideration
How To Write a CPP Disability Request For Reconsideration
CPP Disability Appeal: Social Security Tribunal – General Division
CPP Disability Appeal: Social Security Tribunal – Appeal Division

WE CAN HELP

Reach out for a Free Assessment Today.
Our Dedicated Agents Are Here to Help You Access
the Disability Benefits You Deserve.

1-844-800-6020

info@DisabilityCreditCanada.com

Request a Free Assessment

"*" indicates required fields

LinkedIn

This field is for validation purposes and should be left unchanged.

Name*

First Last

Phone*

Email*

DISABILITY CREDIT CANADA INC.
ADDRESS: 3701 Chesswood Drive, #208 Toronto, Ontario M3J 2P6, Canada
TOLL-FREE: 1-844-800-6020
FAX: 647-846-7542

DISABILITY RESOURCES

DCCI Scholarship for Canadian Students with Disabilities

Facebook Linkedin X-twitter Youtube

Disability Tax Credit Resources

Menu

The Disability Tax Credit Resource Guide (Updated February 2026)
The Definitive Guide To Child Disability Tax Credit
Disability Tax Credit Calculator
Disability Tax Credit Frequently Asked Questions
Disability Tax Credit Form – T2201
Disability Tax Credit Application Process
Disability Tax Credit Eligible Conditions Information

Disability Tax Credit Provincial Resources

British Columbia

Newfoundland and Labrador