Functional Ability Assessment Questionnaire
Please complete this questionnaire to help us assess your ability to perform daily activities. Your responses will assist in understanding your current level of independence.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
Please rate your ability to perform the following activities without assistance.
*
Rows
Independent
Needs Some Assistance
Needs Full Assistance
Bathing/Showering
1
2
3
Dressing
4
5
6
Feeding
7
8
9
Toileting
10
11
12
Mobility (walking, transferring)
13
14
15
Household Chores
16
17
18
Meal Preparation
19
20
21
Medication Management
22
23
24
How would you rate your overall independence in daily activities?
*
1
2
3
4
5
Do you use any assistive devices or aids?
Wheelchair
Walker
Cane
Hearing Aid
Glasses/Contacts
Other
Do you require assistance with any of the following? (Select all that apply)
Personal care (bathing, dressing, grooming)
Mobility
Household chores
Meal preparation
Medication management
No assistance required
Have you experienced any recent changes in your ability to perform daily activities?
Yes
No
If yes, please describe the changes you have noticed.
Please provide any additional comments or information that may help us better understand your functional abilities.
Email Address (optional, for follow-up if needed)
example@example.com
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