Obesity Functional Assessment Form
Use this form to assess how body weight may be affecting daily functioning, mobility, and overall comfort.
Assessment Overview
Reason for Assessment
*
Self-assessment
Clinician referral
Wellness screening
Progress check
Other
Age Range
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Functional Impact
Mobility
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Stair climbing
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Standing tolerance
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Walking distance
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Getting up from a chair
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Bending and reaching
*
No limitation
1
2
3
4
Unable to perform
5
1 is No limitation, 5 is Unable to perform
Summary and Notes
Additional Comments
Overall Functional Limitation
*
No limitation
1
2
3
4
5
6
7
8
9
Severe limitation
10
1 is No limitation, 10 is Severe limitation
Submit Form
Should be Empty: