FUNCTIONAL ASSESSMENT QUESTIONNAIRE
Patient Name:_________________________ Age:_____ Gender: ________ Number of Visits:______
Using the key below please circle one answer in each box that indicates your ability to do the following activities;
Key: (0 = unable) (1 = very difficult) (2 = moderately difficult) (3 = minimally difficult) (4 = normal)
(N/A = not applicable to your current condition)
Activity Score
1. Sleep normally 0 1 2 3 4 N/A
2. Up and Down Stairs 0 1 2 3 4 N/A
3. Food Prep/Cooking/Eating 0 1 2 3 4 N/A
4. Walking 0 1 2 3 4 N/A
5. Grooming (bath, comb hair, shave, etc) 0 1 2 3 4 N/A
6. Getting up/down from chair or bed 0 1 2 3 4 N/A
7. Dressing – manage normal dressing activities 0 1 2 3 4 N/A
7a: Dressing – Tie Shoes/Button Shirt 0 1 2 3 4 N/A
8. Lifting/Carrying up to 10 pounds 0 1 2 3 4 N/A
9. Sitting for normal periods of time 0 1 2 3 4 N/A
10. Standing for normal periods of time 0 1 2 3 4 N/A
11. Reaching above head or across body 0 1 2 3 4 N/A
12. Leisure/Recreational/Sports Activities 0 1 2 3 4 N/A
13. Squatting down to pick up item 0 1 2 3 4 N/A
14. Running/Jogging 0 1 2 3 4 N/A
15. Driving 0 1 2 3 4 N/A
16. Job Requirements – can do all activities required of my job 0 1 2 3 4 N/A
Pain Scale - Please circle the number that describes the pain you have experienced over the last week with 0 being no
pain and 10 the worst imaginable – WHEN NOT TAKING PAIN MEDICATION.
0 1 2 3 4 5 6 7 8 9 10
__________________________________________________________________________________________________
FOR OFFICE USE ONLY
Group Name/Location: _______________/_______________ PT or OT Evaluation or Discharge Date: _____________
Region (use key) __________________________ Diagnosis (use key)_______________________________________________
Therapist Name: ___________________________________ ACS 10-12
