Function Report Checklist worksheet
Use this checklist to organize daily activities, pain, fatigue, help needed, consistency, and third-party notes.
| Item | Your notes |
|---|---|
| Use This Checklist To Organize Daily Activities | ____________________________ |
| Pain | ____________________________ |
| Fatigue | ____________________________ |
| Help Needed | ____________________________ |
| Consistency | ____________________________ |
| Third-Party Notes | ____________________________ |
| Provider | ____________________________ |
| Dates of treatment | ____________________________ |
| Diagnosis or condition | ____________________________ |
| Key test or finding | ____________________________ |
| Treatment tried | ____________________________ |
| Medication or side effect | ____________________________ |
Before you use this checklist
- Copy dates and instructions from the current SSA notice rather than memory.
- Keep originals and work from copies.
- Do not send Social Security numbers, bank information, or full medical files to an unverified recipient.
- Save filing confirmations and proof of any time-sensitive submission.