Long-Form Physical Assessment Form
Please complete this assessment form to provide a comprehensive overview of physical performance and abilities.
Participant Full Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
General Physical Condition
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Mobility Evaluation (Rate the participant's mobility in each area)
*
Rows
Needs Assistance
Some Difficulty
Independent
Walking
1
2
3
Standing
4
5
6
Sitting
7
8
9
Stair Climbing
10
11
12
Flexibility Assessment (Rate flexibility in each area)
*
Rows
Limited
Moderate
Full Range
Shoulders
13
14
15
Hips
16
17
18
Back
19
20
21
Hamstrings
22
23
24
Balance Assessment (Rate stability in each activity)
*
Rows
Unsteady
Occasionally Unsteady
Stable
Standing Still
25
26
27
Walking
28
29
30
Turning
31
32
33
Reaching
34
35
36
Strength Assessment
*
Very Weak
1
2
3
4
5
6
7
8
9
Very Strong
10
1 is Very Weak, 10 is Very Strong
Endurance Assessment
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Overall Satisfaction with Physical Abilities
*
1
2
3
4
5
Additional Comments or Observations
Submit Assessment
Should be Empty: