Life Functioning Assessment
Evaluate your ability to perform daily activities and participate in various areas of life. Please answer each section as accurately as possible.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
How would you rate your ability to perform the following activities in the past month?
*
Rows
Independent
Needs Some Assistance
Dependent
Personal Hygiene (bathing, grooming)
1
2
3
Dressing
4
5
6
Meal Preparation
7
8
9
Medication Management
10
11
12
Managing Finances
13
14
15
Rate your satisfaction in the following life areas.
*
Rows
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Social Relationships
16
17
18
19
20
Work or School Performance
21
22
23
24
25
Physical Health
26
27
28
29
30
Emotional Well-Being
31
32
33
34
35
Community Participation
36
37
38
39
40
How often have you experienced difficulties in the following areas over the past month?
*
Rows
Never
Rarely
Sometimes
Often
Always
Remembering appointments or tasks
41
42
43
44
45
Managing stress
46
47
48
49
50
Sleeping well
51
52
53
54
55
Maintaining a healthy diet
56
57
58
59
60
Staying physically active
61
62
63
64
65
Overall, how would you rate your life functioning in the past month?
*
1
2
3
4
5
6
7
8
9
10
What are your main strengths in daily life functioning?
What are the main challenges or difficulties you face in daily life functioning?
Do you currently receive any support for daily activities?
*
Yes
No
If you answered 'Yes' above, please describe the type of support you receive.
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