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DISABILITY BLUEPRINT LLC
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Today's Date
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Did you have restful sleep last night?
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Yes
No
How many hours of sleep did you get last night?
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Less than 3 hours
3 to 5 hours
5 to 8 hours
More than 8 hours
Were you able to complete any of your daily activities today?
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Yes
No
What activities were you able to complete?
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Cleaning
Cooking
Laundry
Wash Dishes
Shopping
Personal Hygiene
None
Other
On a scale from 1-10, with 1 being not productive at all and 10 being extremely productive, how productive do you feel your day was?
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1 - Not very productive
2
3 - A little productive
4
5 - Somewhat productive
6
7 - Very productive
8
9
10 - Extremely productive
Please describe any symptoms you experienced today.
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Depressed mood
Anxiety
Irritability
Muscle weakness
Diminished interest in almost all activities
Decreased energy
Difficulty walking
Difficulty using your hands
Dizziness
Low back pain
Leg pain
Fatigue
Hand pain
Ringing in ears
Neck pain
Limited range of motion in upper extremities
Limited range of motion in lower extremities
Headaches
Other
Please list the "Other" symptom. If you did not experience any other symptom, type NA.
Did you take all of your medications as prescribed?
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Yes
No
Please add anything else that you think is relevant that happened today. Do you feel like you had a productive day? Did something happen today that aggravate any of your symptoms? Have your providers recommended new treatment?
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Please type your first name and last initials here.
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