Simon looking earnest in Preveza, Greece
Simon Shields, LLB

Ontario Legal Guides
Since 2005

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collection agencies / criminal injuries compensation / sppa (admin law)
/ line fences / animal cruelty / dogs & cats / wild animal law (all Canada) / war / conditions of guide use

home / about / client testimonials / subject areas / about self-representation

Simon Shields,
LLB

Barrister and Solicitor
(Retired)
LSUC #37308N


simonshields@isp.com

Legal Writing and Research


Disability Questionnaire (ver.5)
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HISTORY

1. Name _______________________________ Age ________

2. Life/Family

. Where born? ____________

. Immigration/s? (where and when)

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. Children/Spouse?

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. Present Co-habitants?

_______________________________________________________

. Other

_______________________________________________________

3. Education/Skills

. formal academic achievements(grade and where)?

_______________________________________________________

_______________________________________________________

speak? read? write?

4. Languages
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English | | |
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. driver's license? drive? If not, why not?

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2

5. Work and Income (from first to last)

Years/
Age Entity? What Did? How Long? Why Ended?
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Notes

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3

6. Functional Limitations

(a) Physical

Activity | Problems? | When | Notes |
| | Started? | |
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Pain? | | | |
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Walking | | | |
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Standing | | | |
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Sitting | | | |
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Bending | | | |
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Carrying | | | |
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Lifting | | | |
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Dexterity | | | |
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Breathing | | | |
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Sleeping | | | |
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Toiletting| | | |
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Diet/ | | | |
Nutrition | | | |
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Speaking | | | |
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4

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Hearing | | | |
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Sight | | | |
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Nausea | | | |
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Headaches | | | |
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Dizziness | | | |
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Obesity | | | |
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Notes: ____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

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5

(b) Self-Care

Activity | Problems? | When | Notes |
| | Started? | |
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Feeding | | | |
Self | | | |
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Washing/ | | | |
Bathing | | | |
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Dressing | | | |
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Cooking | | | |
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Dishes | | | |
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Cleaning | | | |
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Laundry | | | |
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Shopping | | | |
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Notes: ____________________________________________________

____________________________________________________

____________________________________________________

6

(c) Community and Workplace Functioning

Activity | Problems? | When | Cause/Notes |
| | Started? | |
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Ambulation| | | |
| | | |
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Limits on | | | |
Going Out | | | |
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Crowds | | | |
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Friends | | | |
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Parenting | | | |
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Clubs/ | | | |
Church | | | |
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Social- | | | |
izing | | | |
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Sexuality | | | |
| | | |
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Anger & | | | |
Violence | | | |
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Criminal | | | |
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Authority | | | |
Figures | | | |
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7

(d) Mental/Emotional

Activity | Problems? | When | Cause/Notes |
| | Started? | |
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Concentra-| | | |
tion | | | |
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Memory | | | |
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Anger/ | | | |
Meekness | | | |
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Alcohol/ | | | |
Drug | | | |
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Mood | | | |
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Notes _____________________________________________________

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_____________________________________________________

_____________________________________________________


_____________________________________________________

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8

7. Treatment/Meds/Aids

Therapy - What and When Started?

Physio? __________________________________________________

Psycho? __________________________________________________

External Services Used - Which and When Started?

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Prostheses Used - What and When Started?
(eg.cane, wheelchair, walker)

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Medications

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Side Effects?

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9

WITNESS/ES


________________________ ________________ ____________
Name Relationship Phone/Contact

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________________________ ________________ ____________
Name Relationship Phone/Contact

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10

DOCTORS

Name Type Address Phone Fax
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Notes

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Lawyer License #37308N / Website © Simon Shields 2005-2018