Common Functional Limitations Checklist

Designed to facilitate discussion and identification of limitations following a

medical diagnosis
Compiled by Sara Sharpe M.S.; C.R.C. with assistance from Deb Henderson-Guenther M.S.; C.R.C.

Adapted from the Disability Handbook, Department of Rehabilitation Education & Research

University of Arkansas

Two Thousand Twelve Edition

 Explanation of References

The vast majority of this work has been adapted from the Disability Handbook, Two
Thousand Twelve Edition (2012) by Jason D. Andrew and M. Jean Andrew. This edition did not
include a robust definition of functional limitations for Autism, so this author referred to the
Center for Disease Control (CDC) to create the Common Functional Limitations Checklist for this
disability.

Sleep Disorders were not given specific functional limitations in the Handbook, resulting
in adaptations from the Job Accommodation Network (JAN) for this disability. Likewise,
Deafness was combined with Hard of Hearing in the Handbook so information for this disability
came from JAN.

References Include:

Accommodation and compliance series: Employees with sleep disorders. (2013, March 26).
Retrieved from http://askjan.org/media/Sleep.html

Accommodation and compliance series: Employees with hearing loss. (2013, March 7).
Retrieved from http://askjan.org/media/hearing.html

Andrew, J. D. (2008) Disability Handbook. 2008 edition

Department of Rehabilitation Education and Research
University of Arkansas

Andrew, J. D., Andrew J.M (2012). Disability Handbook. 2012 edition

Aspen Professional Services

Autism Spectrum Disorders: Signs and symptoms. (2013, May 13). Retrieved from
http://www.cdc.gov/ncbddd/autism/signs.html

Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important considerations for public health.
American Journal of Public Health, 100(6), 1019-1028. doi:10.2105/AJPH.2009.159491
 Table of Contents
Affective Disorders: Bipolar Disorder .......................................................................................................... 1
Affective Disorders: Depression .................................................................................................................. 2
Affective Disorders: Mania .......................................................................................................................... 3
Albinism ........................................................................................................................................................ 4
Alcohol and Other Drug Abuse Disabilities ................................................................................................. 5
Allergies ........................................................................................................................................................ 6
Amputations ................................................................................................................................................. 7
Arthritis ......................................................................................................................................................... 8
Aspergers Syndrome ................................................................................................................................... 9
Asthma ........................................................................................................................................................ 10
Autism ......................................................................................................................................................... 11
Burns ........................................................................................................................................................... 12
Cancer ......................................................................................................................................................... 13
Cardiovascular Disorders ........................................................................................................................... 14
Carpal Tunnel Syndrome ............................................................................................................................ 15
Cerebral Palsy ............................................................................................................................................. 16
Deafness ..................................................................................................................................................... 18
Delusional (Paranoid) Disorders ................................................................................................................ 19
Diabetes Mellitus ....................................................................................................................................... 20
Eating Disorders ......................................................................................................................................... 21
Chronic Fatigue Syndrome ......................................................................................................................... 22
Fibromyalgia ............................................................................................................................................... 23
Hard of Hearing .......................................................................................................................................... 24
Hemophilia ................................................................................................................................................. 25
H.I.V. (AIDS) ................................................................................................................................................ 26
Intellectual Disabilities ............................................................................................................................... 27
Learning Disorders...................................................................................................................................... 28
Chronic Lower Back Pain ............................................................................................................................ 29
Motor Neuron Diseases ............................................................................................................................. 30
Movement Disorders ................................................................................................................................. 31
Multiple Sclerosis ....................................................................................................................................... 33
Obesity ........................................................................................................................................................ 34
Personality Disorders ................................................................................................................................. 36
Post-Polio Syndrome .................................................................................................................................. 37
Post-Traumatic Stress Disorder ................................................................................................................. 38
Renal-Kidney Disease ................................................................................................................................. 39
Respiratory Disorders................................................................................................................................. 40
Schizophrenic Disorders ............................................................................................................................. 41
Seizure Disorder (Epilepsy) ........................................................................................................................ 42
Sickle Cell Anemia ...................................................................................................................................... 43
Sleep Disorders ........................................................................................................................................... 44
Spina Bifida ................................................................................................................................................. 45
Spinal Cord Injury ....................................................................................................................................... 46
Stroke .......................................................................................................................................................... 47
Traumatic Brain Injury ............................................................................................................................... 48
Visual Impairments .................................................................................................................................... 49
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Common Functional Limitations Checklist Associated with Affective Disorders:

Bipolar Disorder
Common Functional Limitations Yes, No, or Dont How will items marked YES be
Know in My Case addressed?
Issues with interpersonal skills
(cooperation, tact, and empathy)

Issues with dependability

Problems with decision-making

Dealing with frequent change

Limited stamina (fatigue and lethargy)

Issues with judgment

Issues with motivation or initiative

Issues with follow-through or ability to

follow instructions

Issues with self-confidence/ self-image

Drowsiness from interrupted sleep

patterns or lack of sleep

Issues with concentration

Memory problems

Issues with stability; consistency of

behavior

his information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.
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Common Functional Limitations Checklist Associated with Affective Disorders:

Depression
Common Functional Limitations Yes, No, or Dont How will items marked YES be
Know in My Case addressed?
Depressed mood; difficulty moderating
mood
Inability to enjoy usual activities
Psychomotor problems (slowness in
speech, thought, and movement)
Problems with decision making
Limited stamina (fatigue and lethargy)
Difficulty with follow-through or following
instructions
Issues with judgment
Issues with motivation or initiative
Bodily complaints: headaches, back pain,
muscle cramps, nausea, etc.
Issues with self-confidence/ self-image

Drowsiness from interrupted sleep

patterns or lack of sleep

Issues with concentration/ loss of interest

Memory problems

Issues with stability; consistency of

behavior

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.
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Common Functional Limitations Checklist Associated with Affective Disorders:

Mania
Common Functional Limitations Yes, No, or Dont How will items marked YES be
Know in My Case addressed?
Issues with interpersonal skills
(cooperation, tact, and empathy)

Issues with dependability

Problems with decision-making

Issues with judgment

Difficulty managing money

Flight of ideas; difficulty organizing

thoughts

Issues with motivation or initiative

Issues with follow-through or ability to

follow instructions

Drowsiness from interrupted sleep

patterns or lack of sleep

Issues with concentration

Memory problems

Issues with stability; consistency of

behavior

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.
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Common Functional Limitations Checklist Associated with Albinism

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Judgment from others over
appearance

Issues with employer and peer

acceptance

Issues with self-concept

Delay in social skills development

Do you have photosensitivity?

Do you have to take precautions
before going outside?
Does your disability cause you to
have problems with:
-reading, writing, driving,
space/form/ depth perception,
field of vision deficit, sensitivity
to glare (photophobia)

Bleeding tendencies- related to

Hermansky-Pudlak Syndrome
(HPS)

Breathing conditions- related to

HPS

Bowel conditions

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Common Functional Limitations Checklist Associated with Alcohol and Other

Drug Abuse Disabilities
Common Functional Limitations Yes, No, or Dont How will items marked YES be
Know in My Case addressed?
Psychological Consequences:
Post-Traumatic Stress Diagnosis
Generalized Anxiety Disorders Diagnosis
Depression Diagnosis
Feelings of guilt/ grief
Difficulty with impulse control
Low frustration tolerance
Lack a perspective of time
Social Consequences:
Difficulty with relationships
Loss of activities of daily living (ADL) skills

Having mostly friends who drink or do

drugs
Lacking positive peer supports

Spiritual Consequences:

Feelings of hopelessness
Feelings of despair

Feeling directionless

Difficulty coping without drinking or

taking drugs

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Common Functional Limitations Checklist Associated with Allergies

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Inability to work outside

Difficulty working in wet, humid

conditions

Difficulty working near fumes

and dust

Limited stamina

Fatigue/weakness

Pain

Sleepiness

Problems with motor

coordination

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Common Functional Limitations Checklist Associated with Amputations

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Upper Extremity:
Grasping
Fingering
Pinching
Limited bimanual capabilities
Carrying
Lifting
Holding
Pushing

Lower Extremity:
Balancing
Climbing
Walking (even and uneven
surfaces)
Stooping
Pushing
Pulling
Carrying large objects

Lifting heavy or bulky objects

Upper or Lower Extremity:

Intolerant of environmental
conditions (heat, cold, humidity,
dirt) with prosthesis wearers

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Common Functional Limitations Checklist Associated with Arthritis

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Upper Extremities:
Fine hand movements
Fingering
Stiffness in joints; affects
dexterity
Grasping
Working above the shoulders
Lack tactile sensation
Lower Extremities (including
back)
Stooping
Bending
Twisting
Lifting
Crawling
Sitting
Balancing
Kneeling
Climbing
Turning
Carrying
Standing
Either Upper or Lower
Extremities:
Movement affected by extremes
of weather/ temperature
conditions

Strenuous activities without

taking frequent rest periods
Trauma/ jarring/ overuse of
affected joints
Pain
Limited mobility
Limited range of motion

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Common Functional Limitations Checklist Associated with Aspergers Syndrome1

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Difficulty choosing a topic of
conversation
Engaging in one-sided, long-
winded conversations
The inability to recognize that
other people think and feel
differently than they do
The inability to understand
nonverbal cues, such as facial
expressions, body language, or
to understand humor
Appearing not to understand,
empathize with, or be sensitive
to others feelings
Speaking in a voice that is
monotonous, rigid, or unusually
fast

Moving clumsily, with poor

coordination
Displaying unusual nonverbal
communication, such as lack of
eye contact, few facial
expressions, or awkward body
postures and gestures
Showing an intense obsession
with one or two specific, narrow
subjects, such as baseball
statistics, train schedules, or
weather

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.

1
Please note that the diagnosis of Aspergers Syndrome has been removed from the Diagnostic and Statistical
Manual, Fifth Edition (DSM-V) which will begin widespread use January, 2014. It has grouped with Autism
Spectrum Disorders.
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Common Functional Limitations Checklist Associated with Asthma

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Walking

Climbing

Lifting

Limited stamina

Sensitivity to cold

Problems managing temperature

changes

Difficulty being in wet, humid

conditions

Problems working near fumes

and dust

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Common Functional Limitations Checklist Associated with Autism2

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Limited vocabulary, echolalia
Understanding language
emphasis and tone variations
Using or understanding non-
verbal means of communication
e.g. eye contact, facial
expressions, body language,
gestures
Difficulty understanding similes,
metaphors, humorous, ironic or
sarcastic remarks
Difficulties in planning and
organizing activities
Difficulty with imagination
Problems understanding
personal space
Trouble understanding the
thoughts, feelings, and
emotional distress in others
and/or talking about own
feelings
Limited or no insight of self
Indulging in repetitive and
stereotypical behaviour
Unusual eating and sleeping
habits
Maintaining rigid and inflexible
routines (e.g. eating the same
food every day, watching the
same videos)
Difficult, bizarre or challenging
behaviour if routine is changed.
Repetition of the same
comments or question
Problems with personal care
Unusual reactions to the way
things sound, smell, taste, look,
or feel

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.

2
Autism Spectrum Disorders: Signs and symptoms (2013)
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Common Functional Limitations Checklist Associated with Burns

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Intolerance to extreme heat
conditions

Judgment from others over

appearance

Fear of meeting the public

Avoidance of activities causing

trauma/ irritation to injured skin
and/or joints

Limited range-of-motion if joints

are affected

Issues with self-image

Issues with employer/ peer

acceptance

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Common Functional Limitations Checklist Associated with Cancer

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Limited stamina

Decreased strength

Lifting ability

Climbing ability

Walking endurance

Intolerance to temperature
changes
Pain
Fatigue
Difficulty breathing
Nausea
Diarrhea or constipation

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.
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Common Functional Limitations Checklist Associated with Cardiovascular

Disorders and Peripheral Vascular Disease
Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Mobility (walking, running,
climbing stairs)

Standing for prolonged periods

(*Has physician contraindicated
standing?)

Lifting, pushing, pulling,

reaching, pressing (*are any back
problems present?)

Limited stamina and/or

endurance

Difficulty managing temperature

extremes
Dizziness
If yes, under what conditions?
Intolerance to environmental
changes (gases, fumes, air
quality, altitude changes)

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Common Functional Limitations Checklist Associated with Carpal Tunnel

Syndrome
Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Fingering

Lifting

Strength

Pain

Grasping

Dexterity

Reaching

Endurance

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Common Functional Limitations Checklist Associated with Cerebral Palsy

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Physical Limitations:
Limited stamina
Pushing, pulling, pressing
Muscular control, coordination,
balance, speed
Ambulation, standing, stooping,
bending, climbing
Writing, driving
Bowel and bladder, pulmonary,
pain
A personal care attendant for
daily living activities (eating,
cooking, dressing, personal
hygiene)
Language and communication:
Hearing disorders
Auditory and visual
comprehension disorders
Issues with distractibility
Speech affected
Psychosocial limitations can
include:
Cognition (verbal perception,
verbal reception, verbal
expression, visual perception,
visual motor)
Problems with memory
Problems with school
achievement
Acquisition retention,
interpretation and application of
information
Issues with social isolation
Problems with dependency and
self-centeredness
Lack of initiation in taking
responsibility
Complications:
Contractures (joint limitations)
Bowel and bladder incontinence
Dental problems
Osteoporosis
Degenerative joint disorders due
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to poorly aligned joints

Scoliosis
Respiratory infections due to
inefficient swallowing and
compromised cough complex
Other Commonly associated
problems or disabilities:
Learning disabilities
(visual/auditory processing)
Intellectual disabilities
Visual and/or hearing problems
Problems developing
independent living skills
Seizures
Fatigue
Problem-solving deficits
Lack of support systems

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Common Functional Limitations Checklist Associated Deafness3

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Difficulty communicating face-to-
face

Difficulty understanding verbal

instructions

Communicating with peers in

groups, meetings, or trainings

Speech clarity
Difficulty responding to sounds
in the environment
Unable to understand the
meaning of sounds

Balance/ motor coordination

problems
Difficulty wearing hearing
protection
Issues with self-image

Deficits in school achievement

Problems in conceptualization
Safely operating or working
around vehicles
Tendency to take things in very
concrete ways
Difficulty communicating by
telephone

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.

3
Accommodation and compliance series: Employees with hearing loss (2013)
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Common Functional Limitations Checklist Associated with Delusional (Paranoid)

Disorders
Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Issues with dependability

Problems conforming to rules

Issues with judgment

Difficulty with logical thinking

Issues with cooperation

Problems with tact

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Common Functional Limitations Checklist Associated with Diabetes Mellitus

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Physical stamina and/or
endurance

Standing

Walking

Motor coordination

Heavy exertion

Tactile discrimination (being able

to feel objects with your fingers)

Finger dexterity

Handling

Grasping

Manual dexterity

Tolerance to extremes in
temperature

Tolerance to long hours without

rest/food intake

Tolerance to occupations that

pose unusual injury hazards
(cuts, burns, skin injuries)

Problems with concentration

Visual acuity

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Common Functional Limitations Checklist Associated with Eating Disorders

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Limited stamina

Strength

Cold

Decisions/judgment (persons
experiencing bulimia are
frequently associated with
impulsive behavior such as
alcohol/ drug abuse,
stealing/shoplifting, and suicidal
behavior)

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Common Functional Limitations Checklist Associated with Chronic Fatigue

Syndrome
Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Overwhelming fatigue that
completely destroys ones
energy and strength

Cognitive problems, lack of

concentration or mental malaise
(brain fog)
Sleep disorder, wakefulness,
unable to go back to sleep
Persistent muscle discomfort and
migratory joint pain
Nagging scratchy and sore throat
Enlarged lymph nodes in the
neck or armpits that are tender
and painful
Mild to severe headaches,
nausea
Depression and anxiety
Side effects and/or reactions to
medications
Muscle atrophy due to lack of
activity
Social isolation caused by fatigue

Lifestyle restrictions

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Common Functional Limitations Checklist Associated with Fibromyalgia

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Constant pain, ranging from a
dull ache to severe and
debilitating
Fatigue frequently resulting from
insomnia or sleep disturbances
such as apnea
Lack of concentration or mental
malaise (brain fog)
Frequent need to use restroom
caused by Irritable Bowel
Syndrome
Recurrent tension-type
headaches and migraines that
can be accompanied by nausea,
vomiting, extreme sensitivity to
light and noise
Depression and mood swings
Low self-esteem
Sensitivity to changes in
temperature, bright lights, odors,
and loud sounds
Painful period and premenstrual
discomfort
Numbness and tingling in the
extremities
Dizziness

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Common Functional Limitations Checklist Associated with Hard of Hearing

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Discriminating sounds (i.e.
frequencies, decibel levels,
speech discrimination)
Difficulty understanding verbal
instructions

Difficulty communicating with

peers or co-workers
Speech clarity

Intelligibility/context meaning of
sounds

Balance/ motor coordination

Issues with self-image

Deficits in school achievement

Problems in conceptualization

Tendency to take things in very

concrete ways

Others misjudging your skills and

abilities

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Common Functional Limitations Checklist Associated with Hemophilia

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Climbing

Stooping, kneeling, crouching

Lifting

Strength

Unable to work in physically

hazardous work settings
Limited range of motion
Chronic pain
Fear of injury that might cause
bleeding

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Common Functional Limitations Checklist Associated with H.I.V. (AIDS)

Common Functional Yes, No, or Dont Know in My How will items marked YES be addressed?
Limitations Case
Problems with
cooperation
Issues with dependability

Difficulty making decisions

Difficulty with frequent

change
Limited stamina
Issues with strength
Sensitivity to temperature
changes
Problems with depression

Feeling fearful

Feeling isolated

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Common Functional Limitations Checklist Associated with Intellectual

Disabilities
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Learning work skills
Problems with self-direction

Problems communicating

Difficulty talking/ relating to

others

Limited work tolerance

Mobility

Self-care issues

Transportation (the ability to

drive a motor vehicle or make
use of public transportation)

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Common Functional Limitations Checklist Associated with Learning Disorders

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Difficulty with organizing work
Time management problems

Conceptualization problems

Decision making problems

Issues with maturity

Challenges with reading, writing,

and spelling

Problems with math calculations

Auditory/ visual memory

difficulties
Problems with form and spatial
perception
Issues with concentration
Issues with attending to a task

Visual motor problems

Issues with abstract thinking
Problems following instructions
Problems with self-image
Issues relating to others
Impulse control problems
Unclear/ vague communication
style
Inability to focus on details
Sequencing problems
Relational distortions

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Common Functional Limitations Checklist Associated with Chronic Lower Back

Pain
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Sitting
Standing

Bending

Twisting

Lifting

Climbing

Carrying

Limited stamina

Pain

Activities in daily living (severe

cases)
Additional limitations due to side
effects of medications

Unable to drive a vehicle for long

periods

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Common Functional Limitations Checklist Associated with Motor Neuron

Diseases (Amyotrophic Lateral Sclerosis (ALS), Progressive Bulbar Palsy, Progressive Spinal
Muscular Atrophy, Charcot-Marie-Tooth, etc.)

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Upper extremity mobility
Strength

Whole body mobility

Problems with self-care

Speech

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Common Functional Limitations Checklist Associated with Movement Disorders

(Ataxia, Dystonia, Huntingtons Disease, Multiple System Atrophy (MSA), Myoclonus, Parkinsons
Disease, Progressive Supranuclear Palsy, Restless Leg Syndrome, Tardive Dyskinesia, Tourette Syndrome,
Wilsons Disease)

Common Functional Limitations Yes, No, or Dont Know How will items marked YES be addressed?
in My Case
Physical limitations:
Shaking (tremors), muscular
control and cramping, poor
coordination, and/or balance
problems
Abnormal eye movements or eye
movements so severe as to
functionally cause blindness
Constipation
Sleep disorders such as insomnia
Language and Communication:
Inability to write legibly
Weakness or inability to control
speech
Tics that can involve the voice or
parts of the body and are seen in
Tourettes syndrome
Psychosocial limitations:
Intellectual deterioration
Personality changes
Confusion
Hallucinations
Memory loss
Fainting
Dementia
Complications:
Permanent physical deformities
Affects the ability to perform
day-to-day activities

Social misunderstanding of the

disorder
Pain and fatigue
Muscle aches and pains
Rigid or stiff muscles
Other commonly associated
problems:
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Depression
Reactions to certain drugs
Anxiety, stress, and tension
Lack of support systems

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Common Functional Limitations Checklist Associated with Multiple Sclerosis

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Talking
Writing

Walking

Climbing

Balancing

Stooping

Kneeling

Crouching

Lifting

Twisting
Reaching

Fingering

Motor coordination
Eye-hand-foot coordination
Limited stamina
Strength
Working in cold conditions
Working in heat conditions
Working in conditions where the
temperature changes frequently
Working in wet, humid
conditions
Vehicle operation

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Common Functional Limitations Checklist Associated with Obesity4

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Walking
Climbing

Balancing

Stooping

Kneeling

Crouching

Lifting

Dressing

Grooming

Limited stamina
Strength
Stigma
Other health concerns (high
blood pressure, diabetes, etc.)
Depression
Low self esteem
Body dissatisfaction

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.

4
Puhl & Heuer (2010)
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Common Functional Limitations Associated with Pain

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Strength
Pushing, pulling, pressing

Climbing

Standing

Walking

Stooping, bending

Lifting

Sitting

Kneeling

Turning, twisting
Carrying

Crawling

Driving
Irritability
Depression
Personality changes
Dependence on pain medication
Cold, sudden changes in
temperature

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Common Functional Limitations Checklist Associated with Personality Disorders

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Problems with cooperation
Issues with tact

Problems with dependability

Judgment challenges

Problems thinking logically

Issues with dependency on

others

Problems with impulse control

Issues with distractibility

Problems tolerating frustration

Difficulty respecting people or

property
Issues with proper dress/ attire

Inflexibility to change

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Common Functional Limitations Checklist Associated with Post-Polio Syndrome

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Pain in muscles or joints
Sleep problems

Breathing difficulties

Swallowing problems

Fatigue

Lifting, reaching, walking,

climbing, balancing, stooping,
kneeling, crouching, twisting,
fingering, motor coordination,
eye-hand-foot coordination

Difficulty with eating, hygiene,

dressing, grooming

Limited stamina and/or strength

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Common Functional Limitations Checklist Associated with Post-Traumatic Stress

Disorder
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Inability to tolerate certain
stimuli

PTSD can be a response to a wide range of traumatic events that may or may not involve
physical injury. Thus it is difficult to generalize about the common functional limitations. The limitations
stemming from PTSD (such as the inability to tolerate certain stimuli) will be connected to the traumatic
event experienced. Because of the broad range of stimuli that trigger the reactive symptoms of PTSD,
there is also a broad range of possible functional limitations due to the PTSD. In addition, the reactive
PTSD symptoms causing these limitations may be entirely distinct from the functional limitations caused
by a traditional disability that is also present (Andrew, 2008, p. 102).

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Common Functional Limitations Checklist Associated with Renal-Kidney Disease

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Limited stamina and/or
endurance

Concentration

Lifting

Climbing

Limited capacity for long hours

without rest

Heavy exertion

Sleeping difficulties

Alertness

Exposure to heat for prolonged

periods
Pulling

Pushing

Problems with problem solving/

decision making

Dialysis schedule interruptions

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Common Functional Limitations Checklist Associated with Respiratory Disorders

(Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, Emphysema, Asthma, Cystic Fibrosis)

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Walking
Climbing

Limited stamina and/or strength

Tolerance to temperature
changes/ extremes

Difficulty being in wet and humid

conditions

Problems being in
fumes/dust/mold/gasses

Pushing/ pulling

Lifting

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Common Functional Limitations Checklist Associated with Schizophrenic

Disorders
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Problems with interpersonal
skills i.e. cooperation and tact
Issues with self-direction
(dependability, decision making,
difficulty with frequent change)
Limited stamina

Problems understanding
instructions (particularly if these
involve understanding underlying
principles, reasoning, etc.)

Motor coordination

Eye-hand-foot coordination

Form perception

Spatial perception

Memory

Problem solving
Issues with flexibility and
adapting to change

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Common Functional Limitations Checklist Associated with Seizure Disorder

(Epilepsy)
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Climbing
Balancing

Motor coordination

Eye/hand coordination

Difficulty being in wet and/or

humid conditions

Difficulty being in noisy

conditions

Problems with memory

Issues with attention span

Difficulty with speed on activities

Inability to operate a motor
vehicle
Low self-concept or low feelings
of worth

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Common Functional Limitations Checklist Associated with Sickle Cell Anemia

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Problems with dependability
because of periodic episodes of
sickle cell crisis
Issues with frequent change
(frequent changes of duties can
cause stress which can
exacerbate the problem)

Strength
Limited stamina
Difficulty working in cold or heat

Problems working where there

are temperature changes

Difficulty working in a wet,

humid environment
Pain (abdominal, back, joints)

Joint stiffness and swelling

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Common Functional Limitations Checklist Associated with Sleep Disorders5

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Daytime sleepiness

Difficulty maintaining
concentration

Memory deficits

Problems with attendance

Decreased stamina

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.

5
Accommodation and compliance series: Employees with sleep disorders (2013)
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Common Functional Limitations Checklist Associated with Spina Bifida

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Ambulation
Pushing, pulling, pressing

Climbing, standing, stooping,

bending

Self-care (eating, food

preparation, dressing, toileting,
rolling over, grooming, hygiene,
etc.)

Wheelchair independence
(transfer, propelling wheelchair)

Control of bowel and/or bladder

Writing

Vehicle operation

Range of motion in extremities

Muscle control, reflex control

Motor coordination,
eye/hand/foot coordination

Grasping, handling, hand/finger

dexterity

Kneeling, crawling, crouching

Lifting, carrying, reaching

Preoccupation with limitation

(adjustment to disability)

Issues with self-confidence, self-

image

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Common Functional Limitations Checklist Associated with Spinal Cord Injury

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Ambulation
Limited stamina
Problems with strength and/ or
coordination

Self-care (eating, food

preparation, dressing, toiletry,
grooming, hygiene, shifts in body
position)
Control of bowel and/or bladder

Range of motion in extremities

Muscle control, reflex control

Grasping, handling, hand/finger

dexterity
Muscle atrophy
Pain

Susceptibility to infections
Pressure sores
Preoccupation with limitation
(adjustment to disability)
Problems with self-image, self-
confidence
May have a lack of initiative,
inflexibility, irritability
Feelings of isolation,
aggressiveness
Anger, depression, anxiety, low
self-esteem

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Common Functional Limitations Checklist Associated with Stroke

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Stamina
Strength

Mobility

Mood and/or behavior changes

Attention, concentration,
memory

Decision-making

Issues with impulse control

Issues with complex skills

Motor control

Speed
Behavior

Problems with social skills

Personality changes

Problems with communication

skills

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Common Functional Limitations Checklist Associated with Traumatic Brain

Injury
Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Balancing, lifting, walking
Strength, coordination
Vision, hearing, communication
skills
Pain and headaches
Problems with memory,
organizational and planning
ability, concrete thinking
Issues with attention span/
distractibility
Writing skills, reading skills,
visual-spatial skills
Problems with lack of initiative,
inflexibility, irritability
Problems with social judgment,
maturity
Problems talking and relating to
others
Feelings of isolation,
impulsiveness, aggressiveness
Problems with anger, depression,
anxiety, low self-esteem
Behavioral problems,
suspiciousness
Low self-care skills, low safety
skills
Problems handling money
Inability to carry out previously
learned tasks
Slowness

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Common Functional Limitations Checklist Associated with Visual Impairments

Common Functional Limitations Yes, No, or Dont How will items marked YES be addressed?
Know in My Case
Reading
Writing

Walking

Driving

Space perception

Form perception

Depth perception

Color discrimination

Field of vision deficit

Night vision deficit

This information is funded by Rehabilitation Services Administration WI Client Assistance Program grant H16A040054.