SSA Form 3373 Function Report: Example Answers for Esophageal Cancer
This guide provides sample answers to SSA Form 3373—the Adult Function Report—based on what someone with esophageal cancer might report when applying for an SSDI claim under the Compassionate Allowance designation. These example answers show how someone might describe their symptoms, daily struggles, and the things they can no longer do or have difficulty doing. Reviewing these sample answers for an esophageal cancer function report can help you understand the kind of information typically included in a Social Security Disability function report.
As you fill out your own SSDI form, be sure to double-check that your answers are consistent with your medical records and with your answers. Pay close attention to estimating how long you can stand, walk, or concentrate. You can compare your answers to different questions to check for conflicting information.
This is a long form. Take your time. Take breaks. As you answer, be mindful of time, conflicts, and frequency:
Did you say that you can stand up for less than five minutes to cook, and then say that you can stand in the shower for 15 minutes?
Did you say you had trouble with your hands because of nerves, then say that you can hold a razor and shave and that you help fold laundry?
Think carefully and cross-check your answers. Inconsistencies and vagueness can delay your SSDI claim or raise unnecessary questions.
Esophageal cancer qualifies under SSA’s Compassionate Allowance program (Listing 13.16), which may fast-track your SSDI claim. While a confirmed diagnosis and medical records may be enough to qualify, SSA may still request Form 3373 to complete your file. If you're asked to complete the form, be honest, clear, and specific—describe how long tasks take, how often you need help, and what symptoms interfere. Don’t be afraid to review the SSA Blue Book regulations to see how your medical records match up.
This guide is for educational purposes only and is not legal advice. These examples are based on a fictional claimant character with medically documented, severe esophageal cancer, and what they might report (if they weren’t fictional). Do not copy responses directly. Your answers must reflect your own daily experience. A link to a blank official SSA Form-3373 is at the bottom of this guide. You can download a form and follow along line-by-line to draft your answers first. Pages 1 and 2 of Form 3373 have official instructions. Do not leave any answer blank.
Section A – General Information About You (Page 3)
Section A collects basic identifying information about the disabled person. If someone else is completing the function report (Form 3373) for the disabled person, the person completing the form will sign at the bottom. The first four questions are about the disabled person.
Name of Disabled Person: First name, middle initial, and last name.
Social Security Number: Of the disabled person.
Daytime Telephone Number: If there’s no direct line, SSA allows you to check a box for a message number or indicate that there’s no phone.
a. Where Do You Live? Check the box that best describes your current living situation (e.g., apartment, house, shelter, group home).
b. Who Do You Live With? Choose whether you live alone, with family, friends, or someone else (with space to describe the relationship).
✅ Note: If you’ve recently changed your address, notify the Disability Determination Services (DDS) office to ensure they have your current contact information on file.
Section B – Information About Your Illnesses, Injuries, or Conditions
5. How do your illnesses, injuries, or conditions limit your ability to work?
I was forced to stop working due to fatigue, frequent vomiting, and severe pain. I can no longer sit upright for more than 30–45 minutes, and I often need to lie down throughout the day. Talking for more than a few minutes can make me cough or feel lightheaded. I have difficulty focusing due to medication side effects and exhaustion. I also can't reliably maintain a schedule. Some days I’m unable to get out of bed due to treatment side effects or weakness. Even part-time or work-from-home jobs wouldn’t be possible because my symptoms are too unpredictable and severe.
Section C – Information About Daily Activities
6. Describe what you do from the time you wake up until going to bed:
I wake up tired most mornings, often nauseous from chemotherapy. It takes me about an hour to feel stable enough to get out of bed. I can brush my teeth and use the bathroom, but I often need to sit while doing so because of dizziness and fatigue. Preparing food is difficult. I can stand for only about 5 minutes before needing to sit. Most of the day I am resting or lying down due to weakness and nausea. I nap 2–3 times a day, sometimes for over an hour, especially after treatment. I may attempt a short walk indoors once a day, but I get winded quickly and need to rest afterward. On chemo days and the few days after, I spend 20+ hours in bed due to vomiting and exhaustion. I go to bed early and wake frequently at night.
7. Do you take care of anyone else (e.g., a child, parent, or disabled spouse)?
[ ] Yes [x] No
If "YES," for whom do you care, and what do you do for them?
N/A
8. Do you take care of pets or other animals?
[ ] Yes [x] No
If "YES," what do you do for them?
N/A
9. Does anyone help you care for other people or animals?
[ ] Yes [x] No
If "YES," who helps, and what do they do to help?
N/A
10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?
I used to work full-time, take my time cooking full meals, drive myself, and do common cleaning tasks around the house—like vacuuming, scrubbing the bathroom, and doing laundry. I also ran errands and went for short daily walks without getting dizzy or short of breath.
Since my diagnosis and treatment began, I'm no longer able to manage these tasks. Standing for more than 5 minutes causes dizziness and fatigue, and I often have to sit or lie down. Even walking across the room can leave me out of breath, especially on chemotherapy days or when my anemia flares up. I’ve stopped driving entirely because the medications and exhaustion affect my focus and reaction time. I can’t safely prepare meals—handling knives or hot surfaces while lightheaded is dangerous. These changes started shortly after my first round of treatment in early 2024 and have steadily worsened.
11. Does your illness, injuries, or condition affect your sleep?
[x] Yes [ ] No
If “YES,” how?
Yes. I wake up multiple times each night due to pain, nausea, and night sweats. I often struggle to fall back asleep and feel unrested in the morning. Swallowing problems and reflux also make me anxious about choking while lying down. I sometimes sleep propped up, but it’s still hard to stay asleep. Even on better nights, I wake up at least 2–3 times.
12. PERSONAL CARE
a. Explain how your disability affects the following:
Dress: I dress slowly and need help with buttons and zippers due to hand numbness and weakness from neuropathy.
Bathe: I use a shower chair when I bathe, which I’m only able to do about 2–3 times per week due to fatigue and dizziness. On better days, I may be able to stand for a few minutes during the shower, but standing for more than 5 minutes usually makes me lightheaded, so I sit most of the time. On bad days, my spouse helps wash my back and hair because I don’t have the strength or coordination to do it safely myself.
Care for hair: I wash my hair only a couple times a week with help from my spouse. I get too tired to wash and dry it regularly on my own.
Shave: I shave less often now and only with an electric razor while seated. I can't safely use a regular razor due to tremors and weakness.
Feed self: I use the feeding tube when swallowing is too painful or difficult. Swallowing solid or even some soft foods hurts most days, and on bad days I can’t swallow at all.
Use the toilet: I can use the toilet on my own but sometimes need help getting up on bad days due to weakness or dizziness.
Other: I struggle with oral hygiene—brushing my teeth and using mouthwash can trigger gagging or nausea.
b. Do you need any special reminders to take care of personal needs and grooming?
Yes. I often forget to brush my teeth or comb my hair because of fatigue or nausea. My spouse reminds me.
c. Do you need help or reminders taking medicine?
Yes. I have a pill organizer and alarms set on my phone, but I still forget occasionally due to memory issues and fatigue. My spouse helps manage my medications.
13. MEALS
a. Do you prepare your own meals?
[x] Yes [ ] No
If “Yes,” what kind of food do you prepare?
Sandwiches, frozen meals, snacks, soup, shakes, when symptoms allow.
How often do you prepare food or meals?
Only on days I feel well enough—maybe 2–3 times a week. Usually just one small item at a time.
How long does it take you?
About 5–10 minutes, usually with resting. I often have to stop mid-task because of weakness or nausea.
Any changes in cooking habits since the illness, injuries, or conditions began?
Yes. I used to cook full meals daily. Now I can’t stand long enough to prepare full meals safely. Swallowing is painful, and I rely mostly on soft foods or liquid nutrition. I also use a feeding tube on days when eating is too difficult. My spouse prepares most meals now.
b. If “No,” explain why you cannot or do not prepare meals.
N/A (since box "Yes" is checked above)
14. HOUSE AND YARD WORK
a. List household chores, both indoors and outdoors, that you are able to do.
I sometimes help fold laundry while seated or wipe down a counter briefly. I can’t vacuum, mop, clean bathrooms, or do any yard work. Most chores are too tiring or require standing, which makes me dizzy or short of breath.
b. How much time does it take you, and how often do you do each of these things?
Only a few minutes at a time, and only once every couple of weeks on a better day. Most days I’m too fatigued. My spouse or caregiver handles the rest.
c. Do you need help or encouragement doing these things?
[x] Yes [ ] No
If “YES,” what help is needed?
I need help with almost all chores. My spouse does most of the cleaning and all yard work. I sometimes need to be reminded or encouraged to try lighter tasks, like folding laundry while seated.
d. If you don’t do house or yard work, explain why not.
I don’t do house or yard work regularly because standing and moving around makes me dizzy, tired, or nauseous. Cancer treatment has left me weak, and overexertion worsens my symptoms.
15. GETTING AROUND
a. How often do you go outside?
Only when necessary—mainly for medical appointments.
If you don’t go out at all, explain why not:
N/A
b. When going out, how do you travel? (Check all that apply.)
[x] Walk
[ ] Drive a car
[x] Ride in a car
[ ] Ride a bicycle
[ ] Use public transportation
[x ] Other (Explain): I use a cane, walker, or wheelchair depending on my strength that day.
c. When going out, can you go out alone?
[ ] Yes [x] No
If "NO," explain why you can’t go out alone:
I get dizzy and weak easily, especially after treatments. I often need help managing the wheelchair or walker in case I get dizzy or tired. I’m afraid of falling or getting stuck without help, so I always need someone with me.
d. Do you drive?
[ ] Yes [x] No
If you don’t drive, explain why not:
I stopped driving in 2024 due to fatigue, brain fog, and slower reaction time from medications and treatment side effects. I don’t feel safe behind the wheel.
16. SHOPPING
a. Do you shop?
[] In stores [] By phone [x] By computer [] By mail
b. Describe What you shop for
Groceries, household supplies, and medical items
c. How often do you shop and how long does it take?
I’m not able to go into stores anymore because standing and walking even short distances makes me dizzy and exhausted. All shopping is done online, and my spouse handles most of it. On good days, I might help place an order if it’s short and simple, but even that can be tiring due to nausea and brain fog.
17. MONEY
a. Are you able to:
[x] No Pay bills
[x] No Count change
[x] No Handle a savings account
[x] No Use a checkbook/money orders
Explain all “NO” answers:
My memory and concentration have gotten worse since treatment started. I get confused by numbers and forget due dates. I can’t keep track of what’s paid or what’s due. My spouse handles all money tasks now.
b. Has your ability to handle money changed since the illnesses, injuries, or conditions began?
[x] Yes [ ] No
If “YES,” explain how the ability to handle money has changed:
Before cancer, I paid bills and kept track of everything myself. Now I get overwhelmed by paperwork and make mistakes. I lose focus or forget what I was doing halfway through. It's too stressful.
18. HOBBIES AND INTERESTS
a. What are your hobbies and interests?
I listen to audiobooks and sometimes watch TV for short periods.
b. How often and how well do you do these things?
Only a few times a week, and usually just for 10–20 minutes at a time. I get tired quickly and lose focus.
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
Before I got sick, I enjoyed reading, cooking, and going for walks every day. Now I don’t have the energy or focus for those activities. I can’t read much because my concentration is poor, and I get worn out fast. I rarely leave the house and don’t do any cooking or gardening anymore.
19. SOCIAL ACTIVITIES
a. How do you spend time with others? (Check all that apply.)
[x] In person [x] On the phone [ ] Email [ ] Texting [ ] Mail [ ] Video Chat [ ] Other (Explain):
b. Describe the kinds of things you do with others.
I might have a short phone call with a family member or friend once or twice a week. Occasionally, someone stops by for a short visit, but I usually don’t feel well enough to talk for long.
How often do you do these things?
Only once or twice a week, and the visits or calls are usually under 10 minutes.
c. List the places you go on a regular basis.
Medical appointments
Do you need to be reminded to go places?
[x ] Yes [ ] No
How often do you go and how much do you take part?
I mostly leave the house for medical appointments, which happen a few times a month. My spouse or caregiver reminds me and helps me get ready. I usually just go to the appointment and come home. I don’t have the energy to do much else or take part in anything social.
Do you need someone to accompany you?
[x] Yes [ ] No
If “YES,” explain.
I need help getting to appointments because I get tired easily, and it's not safe for me to go out alone. I use a walker or wheelchair and often need assistance with walking, navigating, and managing transportation safely.
d. Do you have any problems getting along with family, friends, neighbors, or others?
[x] Yes [ ] No
If “YES,” explain.
Since I got sick, I’ve become more withdrawn and easily overwhelmed. When I’m in pain or nauseous, I can get irritable or shut down in conversations. I often avoid visitors even when they mean well.
e. Describe any changes in social activities since the illnesses, injuries, or conditions began.
I used to be more social and spent time with friends and extended family. Since my illness, I’ve stopped going out and keep mostly to myself. My energy is limited, and I rarely feel up to socializing.
20. SECTION D – INFORMATION ABOUT ABILITIES
a. Check any of the following items that your illnesses, injuries, or conditions affect:
[x] Lifting [x] Squatting [x] Bending [x] Standing [x] Reaching [x] Walking [x] Sitting [x] Kneeling
[x] Talking [x] Hearing [x] Seeing [x] Memory [x] Concentration [x] Understanding
[x] Following Instructions [x] Using Hands [x] Completing Tasks [x] Getting Along With Others [x] Stair Climbing
I can’t stand or walk for more than a few minutes without feeling dizzy or exhausted. Sitting upright too long makes my back hurt. Lifting more than a few pounds is difficult. My throat pain and weakness affect my speech. I get lightheaded easily and have trouble focusing, especially on chemo days. I forget things often and lose track of conversations. I avoid social situations because I’m usually too fatigued to participate or speak clearly.
b. Are you:
[x] Right Handed [ ] Left Handed
c. How far can you walk before needing to stop and rest?
I can usually walk about 30 feet on flat ground indoors, using a cane for support, before I become short of breath or lightheaded.
If you have to rest, how long before you can resume walking?
I typically need to sit down and rest for at least 10 minutes before I can continue, and even then I feel weak and need to move slowly.
d. For how long can you pay attention?
On good days, I can focus for about 10 to 15 minutes before I start losing track of what I’m doing. On chemo days or when I’m in pain, it’s hard to concentrate for more than a few minutes. I often have to reread or ask someone to repeat instructions.
e. Do you finish what you start? (For example, a conversation, chores, reading, watching a movie.)
[ ] Yes [x] No
f. How well do you follow written instructions? (For example, a recipe.)
I can follow short written instructions as long as I can read them more than once and take my time.
g. How well do you follow spoken instructions?
I sometimes forget or get distracted, especially when I’m tired. I ask people to repeat themselves a lot.
h. How well do you get along with authority figures? (For example, police, bosses, landlords, or teachers.)
I generally get along okay, but since getting sick I feel overwhelmed and sometimes get frustrated or shut down in conversations.
i. Have you ever been fired or laid off from a job because of problems getting along with other people?
[x] No
j. How well do you handle stress?
I don’t handle stress well anymore. It makes my symptoms worse, especially nausea, fatigue, and trouble sleeping. Even small things like unexpected calls or appointments can feel overwhelming.
k. How well do you handle changes in routine?
Changes in routine are hard for me now. I rely on a predictable schedule to manage my symptoms, medications, and energy. If something unexpected comes up, it throws off the whole day and makes me more tired and confused.
l. Have you noticed any unusual behavior or fears?
[ ] Yes [x] No
I haven’t noticed any unusual behavior or fears. I just feel more anxious and tired than I used to, especially during treatment weeks.
21. Do you use any of the following? (Check all that apply.)
Assistive Devices I Use
[ ] Crutches
[x] Cane
[ ] Hearing Aid
[x] Walker
[ ] Brace/Splint
[x] Glasses/Contact Lenses
[x] Wheelchair
[ ] Artificial Limb
[ ] Artificial Voice Box
[x] Other (Explain): Feeding tube
Which of these were prescribed by a doctor?
Cane, walker, wheelchair, feeding tube, and glasses were prescribed.
When was it prescribed?
All were prescribed in 2024 after cancer treatment began and mobility and nutritional complications worsened.
When do you need to use these aids?
I use the wheelchair or walker when leaving the house or on days when I feel too weak to walk steadily. On better days, I may use a cane for short distances indoors. I use glasses when reading or watching TV. I rely on a feeding tube when swallowing becomes too difficult or painful.
22. Do you currently take any medicines for your illnesses, injuries, or conditions?
☒ Yes ☐ No
If “YES,” do any of your medicines cause side effects?
☒ Yes ☐ No
If “YES,” please explain. (Do not list all of the medicines that you take. List only the medicines that cause side effects.)
| NAME OF MEDICINE | SIDE EFFECTS YOU HAVE |
|---|---|
| Cisplatin (chemotherapy) | Nausea, vomiting, fatigue, metallic taste, hearing changes |
| Ondansetron (Zofran) | Headache, dizziness, constipation |
| Morphine (pain relief) | Drowsiness, confusion, constipation |
| Dexamethasone (steroid) | Insomnia, anxiety, elevated blood sugar, mood swings |
| Lorazepam (anti-nausea/anxiety) | Drowsiness, foggy thinking, coordination issues |
23. SECTION E – REMARKS
Some days are better than others, but I never know how I’ll feel. Chemo makes me sick, tired, and weak. On bad days, I can’t get out of bed or keep food down. Even on good days, I still need help with basic things like meals, meds, and getting around the house.
I know I said I use a microwave and an electric razor or help fold laundry. I can still use my hands for a few simple things, but only for a short time. My hands get weak, shaky, or numb, and I drop things or need help a lot. I try to do what I can, but it's not consistent.
Sometimes I use a cane, and sometimes I use a wheelchair.
I rely on a feeding tube because swallowing is painful almost every day. Chemo and tumor growth make it hard to swallow most foods, and there are many days when I can’t swallow anything without feeling sharp pain.
I can’t keep a routine anymore. I filled out this form the best I could, but my symptoms change day to day. I hope this gives a clear picture of what I’m dealing with. Thank you for looking over my answers.
Final Section – Signature and Contact Info
At the very bottom of Form SSA-3373, there's a section for the person completing the form to print their name, the date, and contact details.
⚠️ Important: This is not necessarily the disabled person—it’s whoever actually filled out the form.
If you filled it out for yourself, enter your own name and information.
If someone helped you complete it (like a family member, caregiver, or caseworker), they should fill this out.
You’ll need to provide:
Name
Date
Address
City, State, ZIP
Optional: Email address
SSA uses this in case they need to follow up for clarification or to verify who helped complete the form.
Filling out SSA Form-3373 may be one of the hardest parts of applying for disability—especially when you're already fighting to manage your health. But taking the time to describe your daily challenges with honesty and clarity can make a meaningful difference. This guide offers a starting point, not a script, to help you think through what the SSA is really asking. Everyone’s journey is different, but you're not alone in this process. With care, reflection, and support, your story can be told in a way that truly reflects what you're going through. Your story has weight, and your challenges are real. Let them see your pain and your struggles, because nobody understands them more than you.
You can download the official SSA Form-3373 from the SSA website.
Disclaimer: This article is for informational purposes only and does not constitute medical or legal advice. Consult with a qualified healthcare provider for medical questions. Consult with a licensed attorney for legal advice. This article does not create an attorney-client or doctor-patient relationship.
AI Ethical Statement: This article includes information sourced from government health websites, reputable academic journals, non-profit organizations, and generated with the help of AI. A human author has substantially edited, arranged, and reviewed all content, exercising creative control over the final output. People and machines make mistakes. Please contact us if you see a correction that needs to be made.
