Activities of Daily Living Matrix
Use this table to QUANTIFY your limitations for the MEB. For # of Days -
About how many days each week do you consider good relative to average,
average, and bad relative to average. For pain level, what is your pain
level, out of 10, on good, average, and bad days. For Pain Medication,
list each medication and dosage that you take on each type of day.
Beside each activity briefly describe your ability to perform that activity on
each type of day and how your condition effects your performance of each
activity. Be sure to list any tools required to assist in the performance
of each activity.
Add additional activities that may help describe your situation more fully.
|
TYPE
OF DAY |
GOOD
DAY |
AVERAGE
DAY |
BAD
DAY |
|
#
Days |
__/7 |
__/7 |
__/7 |
|
PAIN
LEVEL |
__/10 |
__/10 |
__/10 |
|
Pain
Medication |
|
|
|
|
ACTIVITIES |
|
|
|
|
Getting
out of bed |
|
|
|
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Eating
breakfast |
|
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Performing
Household Chores |
|
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Traveling
to Appointments |
|
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Grocery
Shopping |
|
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Shopping |
|
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Physical
Fitness |
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Recreation |
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Visiting
Friends/Family |
|
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Personal
Hygiene |
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Sleeping |
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