• Older Adult Functional Status Assessment Questionnaire Form

    Please complete the following assessment to help evaluate functional abilities and daily living activities. This form is designed for a comfortable and modern experience.
  •
  • Can you get dressed without assistance?*
  • How much difficulty do you have with walking across a room?*
  • How often do you participate in social activities (e.g., clubs, groups, family gatherings)?*
  • How much assistance do you need for toileting?*
  • Indicate your ability to use the telephone (including mobile devices).*
  • Input Table: Please indicate your level of independence for each activity below.*
    Rows
  • Should be Empty:
Select theme: