8/7/2019 Rebab Checklist

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Part f. in rr'.r,"*"'incal,,"' z,pul m "X" besidcthc m.in rh ingsprcvcnllngor discoura8ingyo( lromrcrurn,inglo yourregularlifestylc(indicaldnl llhc reasonsth.l applyt) yo!). Th.n,complet€ Part 2 as instrucredbrlo$.

l. ) Physicalr€strictionsin (check):

2.) l lcadaches

l.) Problenswith diziness4.) Pains.)

7 . )s. )9 . )10 . )I l . )l l . )r3 . )

Dbcnding dlifling Oseeitrgmd/or Oreaching

l: . ) I )cp.ession21.) |lnbnrrlsscdrboutdisabililydr socinldiscriminatio

l:1.)l-ackol cducat ioror sl i l lsi5.) Fc\\'j0bsavailablcin honearcr

16.) Mcnrtllf or leamingproble|ni17.) Luckof enerSy.fcelingiltigucd18.) (onr lbr lwithpresentl i lcstylc19.)Lcg.t lproblens20.)An\ietyor strcss21.) Unablelo cngnSeinsponsor hobbies

2,1.)I)angcr0l prc\ious\\'orl25.) Problcnrswirh(check):

26.) CoDcc|llrfllir problcms27.) Not suilcd$ previouswork28.)Dil ] lcultylcarmDg

ona newJob29.)ScxLll | ldif icul ly30.)Dif t lcultycngngiDgin socialnct ivir ics31.)Dcpcndenceor problenrswnh(chcck):

SpeciSIocaLion\innr ior iL) lDillicultyobtainingajob dueto my disubilityProblcnrswith nry cmployerFcrr ofr€irjury or worseningconditionI) i i l icul lyslccpingEmolionalproblemsl,rohlcnrswith (chcck);

Dislikeofprc!iousr.ork or workplaceI)ifiicnlty lindingNell-payingjobsJobsrcsso. adjusttugto chrnginSjobdcnuMs

Spcciry:Omarriagcihnrily or Olackoi support

Specifyl

OdrivinSlnd/or Olakingpublicrransportation

Omedicntionan&)r Clsideefects

' lr (xJrngUqf l l I r t rn( lur LrrarhrnellLOspeakiDsOhearingaod/orOv'sron

Onishhnres and/orOfl ashbacts

l l . )

13.)l.l. )

16 . )17.) Il|nployerdiscriminafior)38.)I ' roblcnrs! \ i !h(check):

39.) Problcnrswith (check)l

40.)PoorIngl islrski l ls

.,1I.) Acciden!-rclalcd(check):ll.) feir ol driving.\'ork cnlironment.43.) Initrbili ty/ang.r .ont.ol4.1.)Finrnci! ldi l l iculr ic\(check):45.)Scizurcs

Difficuhyndjusringto a newiobWorriedaboutlayofffearol dyingduerocuncDtmcdicalcon( lnio| lDcpcndenccupon/probl€ms$iLh(chcck): Oalcoholand/orOstreetdrugsI)ifficuhyllnding\a) lronc or ro orhcrplrcc

Oinsurance-relrcd and/orOpersonal

16.) Adjustiogro sehooldenands47.) Prcblcnrsorganizing,planning.nrrkintsdccisions.or problelrlsolvhS18.) Problems\!ith balance49.) Rcslriulcdphysicalrnobilitvandiorlilnitationsin self-carc(drcssig. ba ing, ctc.)50.) Olhcf Spccif),:

Use C,/,/,, B !bo!c ro iidi.xte th.Jire nost ittportdt i cnis ilon rlt o.cs fulltosc) rlrt yo! nukcd in Colum A.

numbcr"I bcs c rhc &,\t inrponantproblem. l ll tr Ll,cy.r/r' hNL inrDonanr.up to '5 nr ftcy'Tir nost iqDrlinr

Client lD:_File Nunbcr:Today\ Date:_/_/_ CondilionOnsciDate: / |Agc: Scx: Administration#: | 2 3 4Disability:

PleascContinueon lhe I-.rstPaee

8/7/2019 Rebab Checklist

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Part 3 - Degreeof Life.Role DisabilityPle$e placcan'tC'in the appropriab box under Degreeoflife Role Dis.b lty in tle largetable below. indicating hownuch your conditiotr inpails your ability to engagein thc activitics listcd bclow.

Priorities

CD

Degreeof Life-Role Disability tp"nrl

l.) Householdchores2.) Relationshipswith friends and family3.) Parcntalactivity4.) Volunteerwork or comrnunitywork5.) Relationshipwith spoutdpafoer6.) Scxualactivity7.) Sclf-sufiiciencyin d.e,ssing,eating etc.8.) Panicipationinsports,hobbics9.) Participationin social activities10.) Lcamins/studyingI l.) Rcgular cmployment12.) Ove6ll, how disablcddoyoufccl youarc?

Part 4 - Life Role Priorities

OnceyouhavecompleredPart3,plc!.{cgo backandu.\c.?rrrrmzC undcrPrioritics!o ftlr l\e/ive nos inporranrm/.T inyour lifelrsrp theonsetofyour medicalcondition.Assignthenurnber" l" to thc ,1.,l1importantlifc an4 '2" for Iheis.(r't../mostimportant,up 0o'5" for lhcff, mostimportanLln colam D, r,nicj'e whatyouthink will bethe five mosl importantmles&/)o,rtt 't.

Part5-ConditionChangel. Msrl an'X" in a box bclo*, indicadnghowyourprr5 .r, @ndition h&schegql sinc the onst of yourcondilion. A | 00%

improvement refl€crs a retrm lo how you wcrc /r),ri.a4y bcforc your condilion bcgan.

f00% 90% 80% 10% 60% 50% 4016 30t, ?09$ r0* ro+ 20*' :ros 40sn 50* 60% 70% 80* 90% t00%

2. Mark ar "X in a box belox indicating howyour.rrlrral conditionh6 chanScdsincc thc oruct ofyour condition. A I0O%improvcmc rcnecb a rctum to howyo! |'erc .notiondlly bcforcyourconditionbcgan.

f00% t0s 20% loE 40*

l0,n 20*. l0* 40%

50%

50''

60c 10q 80% 904, 100%

70.t uoq, 90* t00%

3. ln thcluturc.how muchch$ge doyouexp&t in yourconditioroEral? Indicatewilh m 'X ' in aboxbclou A I00% improvement

rcflcctri a rctum to how you were (,sall before your condition bcgan.

100% 906 E0'. 704 40% t0,t, 204 t0 60tx.

7 to 12 Morc ThanMonths I Ycar

5_

Pu1an "X" in thc appropriatcboxiDdicatingwhcDyou lhink youmay

bcwellenough1ocarryout moslof

yournormalaclivitieso. rcles.

Put o 'X" ir thc appropriate boxindicatingwhenyou think th.t youDay be well crougl to rctum bsonc typc olwort on ei0eta tull-

Ma.k wherher this would likcly be:(Put u "X itr the appropriare box

I t o 2Immediately Months

I t o 6Months

3 t o 6MonthsN/A Immcdiately

7 to 12 More ThanMoDths I Year Ncvcr

Resular Modificd

I t o 2Months

6. N/A

40* 50% 60% 70% ao% 9.)% tw*

Full Timc Part-Time

lEI/| ' IIS .@g[J. rqr h4ksber d Mdr{d6 sy<d rr. ^'ridBEnh'5!d4 rtuvrdM^tga,r@oN M2Hr{r.(e):Mr| hldiEt r{rsrM f4