How you can help your medical practitioner complete the DTC medical form
Impact on daily living activities
Here are some examples of how you might describe the impact on daily living activities.
Here are some examples of how you might describe the impact on daily living activities, if applicable for you:
Meal Preparation
- I have difficulty with meal preparation due to severe pain and restricted mobility
- I am unable to use my hands to stir, chop, peel, open jars due to severe pain, hand tremors and low grip
- I am restricted in my standing and lifting to prepare a meal
- I require frequent breaks when preparing meals; compared to an average person my age with no restrictions it takes me three times as long to prepare a meal.
- I have low motivation and a severely low appetite and therefore I do not prepare meals
- My family will prepare meals for me and try to get me to eat. They will bring my meals to bed for me.
Managing Finances
- I get severely overwhelmed and anxious when attempting to manage my finances
- I forgot to pay my bills due to restricted memory
- Due to poor impulse control, I have difficulty maintaining my budget
Shopping for Personal Needs
- I am severely restricted in grocery shopping
- Walking, standing, and lifting is all severely restricted which makes it difficult to shop
- I use a wheel bag that I can put a few light groceries in, however this elevates my pain and I require rest afterwards
- I receive assistance from my family with shopping
Housework
- I experience elevated pain when I try to do housework
- Tasks such as doing laundry, doing dishes, vacuuming and overall cleaning severely elevate my pain
- I am unable to iron my clothes at all due to severe pain
- I require assistance from my family with housework
Self-Care
- I am required to sit in the shower due to chronic pain
- I am required to sit down when getting dressed due to poor balance
- Lifting my arms up to put on shirts elevates my pain
- Severe difficulty and elevated pain when trying to use hands for things like buttons, zippers, belts and tying shoes
- Compared to an average person my age without any restrictions it takes me three times as long to get dressed
Medication Management
- I require a pill pack to help me remember to take my medication
- I require assistance from my family to help me with opening my pill bottles due to my restricted usage of my hands
- I require my pharmacy to deliver my medications due to poor memory
Transportation
- Due to severe pain, I am severely restricted in my ability to use transportation
- I am unable to take public transit due to my restricted mobility. I am unable to walk, stand or sit for extended periods of time to use public transportation.
- My family members will drive me to my appointments
Decision Making
- I am very easily overwhelmed and anxious
- I get confused and I do not understand
- I have avoidant behavior
- I require the assistance of my family members in making decisions
Relating/Communicating with Others
- I am very withdrawn and isolated
- I spend most of my time in bed trying to relieve pain
- I do not see friends or go out and socialize
- I am anxious around others
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