Clinical Functional Capacity Questionnaire Form
Please complete this assessment to help us understand your current physical abilities and limitations. Your responses will guide your clinical care. Do not include sensitive personal details.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Gender
*
Female
Male
Other / Prefer not to say
How would you rate your overall physical function today?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Please indicate your ability to perform the following activities:
*
Rows
No Difficulty
Some Difficulty
Unable to Perform
Walking short distances
1
2
3
Climbing stairs
4
5
6
Lifting/carrying objects
7
8
9
Standing for 10 minutes
10
11
12
Getting in/out of a chair
13
14
15
Do you currently experience pain that limits your activities?
*
No
Yes, mild
Yes, moderate
Yes, severe
How much fatigue do you feel during daily activities?
*
None
0
1
2
3
4
5
6
7
8
9
Extreme
10
0 is None, 10 is Extreme
Are there any specific activities you find most challenging?
Additional Comments (optional)
Submit Assessment
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