Duties Performed Under Duress at Work & Home (DPUD)

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Today's Date: *

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Your Full Name: *

Date of Injury: *

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Signature (Initials): *

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Column 1

Initial (done within first visit or shortly after)

Update

Please check all that apply to your WORK because of the accident/injury.

Column 1

I go to work but work in pain

I limit my work activities

Bending at work hurts

Stooping at work hurts

Sitting at work hurts

Using the computer at work hurts

Pushing at work hurts

Pulling at work hurts

Kneeling at work hurts

I have lost status in my company

I have lost job security

I didn't get a promotion

I don't enjoy work as much as before

I doze off at work

I take unpaid time off work to go to Dr.

I daydream at work more than before

I feel tired at work

I work in pain because I have bills to pay

I can't take time off because I would lose my job

I keep working so I don't lose status at company

My business would fail if I took time off

I believe in working even when I'm in pain

I feel obligated to work even though I'm in pain

My business would lose money if I took time off

My work is not as good as before the accident

My boss reprimanded me for poor performance

I got a different job in another company

I got a different hob within the same company

I make less money than before the accident

I cannot do the same work/job as before the accident

I can't concentrate as well at work

I take paid time off to go to the Dr.

I make mistakes at work I didn't used to

I hide my poor performance at work from my boss

I need medication to be able to work

Column 1

I go to work but work in pain

I limit my work activities

Bending at work hurts

Stooping at work hurts

Sitting at work hurts

Using the computer at work hurts

Pushing at work hurts

Pulling at work hurts

Kneeling at work hurts

I have lost status in my company

I have lost job security

I didn't get a promotion

I don't enjoy work as much as before

I doze off at work

I take unpaid time off work to go to Dr.

I daydream at work more than before

I feel tired at work

I work in pain because I have bills to pay

I can't take time off because I would lose my job

I keep working so I don't lose status at company

My business would fail if I took time off

I believe in working even when I'm in pain

I feel obligated to work even though I'm in pain

My business would lose money if I took time off

My work is not as good as before the accident

My boss reprimanded me for poor performance

I got a different job in another company

I got a different hob within the same company

I make less money than before the accident

I cannot do the same work/job as before the accident

I can't concentrate as well at work

I take paid time off to go to the Dr.

I make mistakes at work I didn't used to

I hide my poor performance at work from my boss

I need medication to be able to work

I take ______ mg of ______________ at _______ am (morning) when my pain level gets to ______/10 (pain scale 1-10)

And/or I take ______ mg of ______________ at _______ pm (evening) when my pain level gets to ______/10 (pain scale 1-10)

Please check all that apply to your HOME/DOMESTIC duties because of the accident:

Check if True

My house is not as clean now

My yard is not as neat now

My garden is not as productive now

I do yard work, but do it in pain

I cannot do my normal yard work

Doing laundry hurts me

I cannot do laundry now

Washing dishes hurts me

I cannot wash dishes now

Vacuuming hurts me

I cannot vacuum now

Cooking hurts me

I cannot cook now

Washing the car hurts me

I cannot wash my car

I asked someone for unpaid housekeeping help

I had to hire a housekeeper

I had to hire a paid gardener

Mowing the lawn hurts me

I cannot mow the law

Taking out the trash hurts me

I cannot take out the trash

I do not enjoy gardening/yardwork like I used to

I do not enjoy housework like I used to

I cannot do my gardening at all since the accident

Others living with me do my share of the work now

I cannot take time off because I care for my children

Check if True

My house is not as clean now

My yard is not as neat now

My garden is not as productive now

I do yard work, but do it in pain

I cannot do my normal yard work

Doing laundry hurts me

I cannot do laundry now

Washing dishes hurts me

I cannot wash dishes now

Vacuuming hurts me

I cannot vacuum now

Cooking hurts me

I cannot cook now

Washing the car hurts me

I cannot wash my car

I asked someone for unpaid housekeeping help

I had to hire a housekeeper

I had to hire a paid gardener

Mowing the lawn hurts me

I cannot mow the law

Taking out the trash hurts me

I cannot take out the trash

I do not enjoy gardening/yardwork like I used to

I do not enjoy housework like I used to

I cannot do my gardening at all since the accident

Others living with me do my share of the work now

I cannot take time off because I care for my children

I have __________ (number) of children ages ______________ (write ages)

In your own words, describe in detail how this accident has affected your work, home and social life. *

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