Physiotherapy Functional Assessment

Functional Assessment No Limitation Severe Limitation Unable

Can reach over their Can reach to the back Can reach behind the Can reach the top Can reach above shoulder Unable to reach above
Seated Shoulder External shoulder to between their of the neck head to level of ears of their head level but not touch the top shoulder level without
Rotation Flexibility shoulder blades of their head pain or movement
limitation
Denote L and R arm in box (es) 1 2 3 4 5 6
Can reach to behind the Can reach to behind Can reach behind to Can reach behind to Can reach behind to Unable to reach behind
Seated Shoulder Internal back to touch their shoulder the back to touch just mid-back level waist level buttock level their back. Pain or
Rotation Flexibility blades below the shoulder movement limitation
blades
Denote L and R arm in box (es) 1 2 3 4 5 6
Able to reach to mid-calf of Able to reach just past Able to reach to knee of Able to reach to Able to reach to knee but Unable to reach forward
Seated Hamstring Flexibility extended leg knee of the extended the extended leg mid-thigh of the unable to complete with because of pain,
leg extended leg correct technique deformity or fear of falling
Denote L and R arm in box (es) 1 2 3 4 5 6
Able to turn safely in 4 Able to turn safely in 6 Able to turn safely in 8 Needs close Needs assistance from one Needs assistance from
180 Degree Turn steps or less steps or less steps or less supervision and person or furniture to turn two people to turn
verbal cueing for
safety. Takes
9-12 steps
Number of Steps: 1 2 3 4 5 6
Reaches greater than 35 Reaches between Reaches between Reaches between Reaches less than Unable or afraid to reach
Functional Reach cm 25 – 34 cm 16 – 24 cm 10 – 15 cm 10 cm forward

Use of Walking Aid? cm….. 1 2 3 4 5 6

Able to rise from chair Able to rise from the Difficulty on rising from Difficulty on rising Difficulty on rising from Unable to rise from the
Timed Up and Go easily, walk unaided, turn chair without arms. Chair. Walks aided or from chair. Walks chair. Needs walking aid. chair, walk or turn without
without dizziness or Walk unaided. Turn unaided but takes aided or unaided Unconfident or dizzy on help
stumbling. Faster than 8 without stumbling. between but takes between turning. Takes 40 seconds
seconds Between 9-15 seconds 16-24 seconds 25-40 seconds or over
Use of Walking Aid? 1 2 3 4 5 6
Time (seconds)
Additional Test: Stand on one leg as long as you can without holding
Standing on One Unable to try or needs Tries to lift leg unable to hold for 3-seconds Able to lift leg and hold Able to lift leg independently and Able to lift leg and independently and
Leg assistance to prevent fall but remains standing independently = or > 3 seconds hold for 5-10 seconds hold > 10 seconds
Score 0 1 2 3 4
Sign: Print Name: Designation: Initials: Time & Date:
Sign: Print Name: Designation: Initials: Time &Date:

FPS 005 Physio Functional AX V1.0 1/2 July 2012

 Flow Diagram for Prospective Participants in Exercise Sessions to
Improve Postural Stability and Reduce Falls and Injuries

Referrer Selection Criteria Functional Exercise Groups

Assessment Grid

MOSTLY TICKS

COMMUNITY EXERCISE
P
SELF – 1 CLASS R
REFERRED O
2 POSTURAL G
THOSE MEETING STABILITY R
INCLUSION 3 E
CLASS S
GP PRIMARY CRITERIA AND 4 S
CARE HAVING NO
EXCLUSION W
5 PREDOMINANTLY I
CRITERIA CHAIR BASED T
PHYSIOTHERAPY CLASS H
REHABILITATION
SETTING T
6 REHABILITATION I
THERAPY M
E

Sign: Print Name: Designation: Time: Date:

FPS 005 Physio Functional AX V1.0 2/2 July 2012