Functional Status Evaluation Questionnaire
Please complete the following questions to help us understand your current functional abilities. This form is for general evaluation purposes only.
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
How would you rate your ability to perform daily activities (such as dressing, bathing, or preparing meals)?
*
1
2
3
4
5
How easily can you move around your home or community?
*
No difficulty
Some difficulty
A lot of difficulty
Unable to do without help
Do you require any assistive devices or help from others for routine tasks?
*
No assistance needed
Occasional assistance
Frequent assistance
Always need assistance
How would you describe your ability to participate in social or recreational activities?
*
Fully active
Mostly active
Somewhat limited
Very limited
Are you able to manage your own personal care (such as bathing, grooming, or using the bathroom)?
*
Independently
With some help
With frequent help
Unable without help
Do you have any comments or concerns about your current functional abilities?
Submit
Should be Empty: