Patient Functional Assessment Questionnaire
Please complete this form to help us assess your current level of function in daily activities.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate your current level of independence for each activity below.
*
Rows
Independent
Needs Some Assistance
Dependent
Bathing
1
2
3
Dressing
4
5
6
Feeding
7
8
9
Toileting
10
11
12
Mobility (walking, transferring)
13
14
15
Grooming (brushing teeth, hair)
16
17
18
Managing Medications
19
20
21
Household Tasks
22
23
24
Communication (speaking, understanding)
25
26
27
How would you rate your current pain level?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Do you currently use any assistive devices? (e.g., cane, walker, wheelchair)
Cane
Walker
Wheelchair
Hearing Aid
Other
Please describe any recent changes in your functional abilities or new difficulties you have experienced.
What is your primary goal for rehabilitation or therapy?
Please indicate any additional health conditions that may affect your function (e.g., arthritis, stroke, vision loss).
Submit Assessment
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