Patient-Specific Functional Scale

Patient-Specific Functional Scale

I need you to list 3-5 important activities that you are unable to do or are having difficulties with as a result of your injury.
  • MM slash DD slash YYYY
  • Functional Activity #1

  • (ie; lifting a box from the floor to waist height. Which could translate into; lifting a full laundry basket from the floor to the counter)
  • 0- Unable to prefrom this activity2345678910 - Able to perform activity at same level as before injury
  • Functional Activity #2

  • (ie; lifting a box from the floor to waist height. Which could translate into; lifting a full laundry basket from the floor to the counter)
  • 0- Unable to prefrom this activity2345678910 - Able to perform activity at same level as before injury
  • Functional Activity #3

  • (ie; lifting a box from the floor to waist height. Which could translate into; lifting a full laundry basket from the floor to the counter)
  • 0- Unable to prefrom this activity2345678910 - Able to perform activity at same level as before injury
  • Functional Activity #4

  • (ie; lifting a box from the floor to waist height. Which could translate into; lifting a full laundry basket from the floor to the counter)
  • 0- Unable to prefrom this activity2345678910 - Able to perform activity at same level as before injury
  • Functional Activity #5

  • (ie; lifting a box from the floor to waist height. Which could translate into; lifting a full laundry basket from the floor to the counter)
  • 0- Unable to prefrom this activity2345678910 - Able to perform activity at same level as before injury