Simon's Legal Resources

(Ontario/Canada)

EVIDENCE | ADMINISTRATIVE LAW | SPPA / Fairness (Administrative)
SMALL CLAIMS / CIVIL LITIGATION / CIVIL APPEALS / JUDICIAL REVIEW / Something Big

Home / About / Democracy, Law and Duty / Testimonials / Conditions of Use

Help Isthatlegal Grow


TOPICS

(What's a Topic?)



Disability Questionnaire (ver.5)
================================

HISTORY

1. Name _______________________________ Age ________

2. Life/Family

. Where born? ____________

. Immigration/s? (where and when)

_______________________________________________________

. Children/Spouse?

_______________________________________________________

. Present Co-habitants?

_______________________________________________________

. Other

_______________________________________________________

3. Education/Skills

. formal academic achievements(grade and where)?

_______________________________________________________

_______________________________________________________

speak? read? write?

4. Languages
-------------------------------------------------------
English | | |
-------------------------------------------------------
| | |
-------------------------------------------------------
| | |
-------------------------------------------------------

. driver's license? drive? If not, why not?

_______________________________________________________

2

5. Work and Income (from first to last)

Years/
Age Entity? What Did? How Long? Why Ended?
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------
| | | | |
| | | | |
------------------------------------------------------------

Notes

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

3

6. Functional Limitations

(a) Physical

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


4

-----------------------------------------------------------
Hearing | | | |
| | | |
-----------------------------------------------------------
Sight | | | |
| | | |
-----------------------------------------------------------
Nausea | | | |
| | | |
-----------------------------------------------------------
Headaches | | | |
| | | |
-----------------------------------------------------------
Dizziness | | | |
| | | |
-----------------------------------------------------------
Obesity | | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------
| | | |
| | | |
-----------------------------------------------------------

Notes: ____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________





5

(b) Self-Care

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

Notes: ____________________________________________________

____________________________________________________

____________________________________________________

6

(c) Community and Workplace Functioning

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




7

(d) Mental/Emotional

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

Notes _____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________


_____________________________________________________

_____________________________________________________

_____________________________________________________




8

7. Treatment/Meds/Aids

Therapy - What and When Started?

Physio? __________________________________________________

Psycho? __________________________________________________

External Services Used - Which and When Started?

-----------------------------------------------------------

-----------------------------------------------------------

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

----------------------------------------------------------

----------------------------------------------------------

Medications

----------------------------------------------------------

----------------------------------------------------------

----------------------------------------------------------

----------------------------------------------------------

----------------------------------------------------------

----------------------------------------------------------

Side Effects?

__________________________________________________________










9

WITNESS/ES


________________________ ________________ ____________
Name Relationship Phone/Contact

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

________________________ ________________ ____________
Name Relationship Phone/Contact

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------
















10

DOCTORS

Name Type Address Phone Fax
===============================================================
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------
| | | | |
| | | | |
---------------------------------------------------------------


Notes

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

--------------------------------------------------------------

CC0

Unless authorship is otherwise stated or obvious from the context, all
written materials in this website were created by Simon Shields, who
waives all of his copyright and related or neighboring rights to this
Isthatlegal.ca webpage. Note in particular that this waiver only applies to
Simon's material, as copyright in statutory/regulatory materials and
case extracts were never his to give away.




Last modified: 11-01-23
By: admin