Functional Activities Questionnaire

Functional activities questionnaires are mainly used in the health sector to gauge the functions of a specific group of people. In hospitals, such questionnaires are used to determine whether patients who had been admitted in the facility for treatment have recovered enough to justify dismissal. The questionnaires can be self –administered, where a patient is given a survey form to fill in his/her responses in the most convenient time, or a nurse can sit through the questionnaire with the patient. In the past, such questionnaires have been criticized because of their length, which was thought to contribute to inaccurate reports. Below is a sample functional activities questionnaire.

Name: ___________________________________________________________

Suffering from: ____________________________________________________

Rate your capabilities in the below named activities as follows;

1- Great difficult doing it by myself

2- Requires assistance

3- Completely dependent on someone else

4- I can handle it normally


a.Balancing my checkbook, paying bills and writing checks ________

b.Keeping track of current affairs __________

c. Going shopping unaccompanied for either groceries or household necessities _________

d.Working on my hobbies, playing XXX game ___________

e.Cooking a good meal unassisted ___________

f.  Switching on the coffee maker, turning on/off the stove or heating water for domestic use ____________

g.Paying attention to conversations, contributing on the same and having fun with friends _______________

h.Remembering important dates such as doctor’s appointment, birthdays, anniversaries and family occasions ______________

i.  Paying attention to the TV, movies or participating in book clubs ______________

j.  Driving, taking public transport or cycling out of the neighborhood unaccompanied ________________

k.Taking medicine in the right doses and at the right time _____________

Category: Fun Questionnaire, Health Questionnaire

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