Activities of Daily Living Form
Frank Bendiks, DC, PC (630) 301-0054 office (630) 355-8983 fax
Instructions:
Spine problems often interfere with a person's ability to perform certain common "activities of daily living". Please read the list below and indicate "Y" (yes) or "N" (no) to those activities that are detrimentally impacted by your current condition.
Patient Name (required)
*
First Name
Last Name
bending
Y
N
car exiting (getting in and out of your car)
Y
N
climbing
Y
N
computer activities
Y
N
cooking
Y
N
dressing
Y
N
driving
Y
N
eating
Y
N
exercising
Y
N
gardening
Y
N
grasping
Y
N
grooming
Y
N
housework
Y
N
irritability
Y
N
lifting
Y
N
lying in bed
Y
N
reading
Y
N
recreation
Y
N
rising from lying
Y
N
rising from sitting
Y
N
rotating neck
Y
N
rotating back
Y
N
sexual difficulty
Y
N
shopping
Y
N
sitting
Y
N
sleeping
Y
N
sports
Y
N
stair climbing
Y
N
standing
Y
N
stress
Y
N
traveling
Y
N
twisting
Y
N
walking
Y
N
washing
Y
N
working
Y
N
my pain is worse in the morning
Y
N
my pain is worse in the afternoon/evening
Y
N
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