Functional Status Questionnaire

The functional status questionnaire is common use in clinical practices for purposes of providing an all-inclusive and feasible appraisal of psychological, physical, role functions and social abilities in ambulatory people. The questionnaire is used by clinicians to monitor or screen the functioning abilities of a patient on different areas of living. Such include role functions, Psychological functions, physical functions (activities involved in daily living) and social functions. Usually, patients are requested to answer all questions regardless of how long the questionnaire may be. In addition, they are requested to provide honest answers so that the necessary attention and care can be provided to them depending on how they score on the questionnaire.


Functional Status Questionnaire

Activities of Daily Living

a.       Have you had any difficulties while feeding yourself, bathing or dressing in the last two months? ______________

b.      Do you struggle to sit up from a chair or get up from the bed? _________

c.       Is moving around in the house problematic for you? _______________

d.      Can you easily walk several blocks outside your home without assistance? _______

e.       Can you walk up or down the stairs in your home or any other place?  ________________

f.        Are you able to carry out simple chores in the house, such as cleaning, home maintenance or yard work? ___________

g.       Can you go grocery shopping or any other place outside the home without needing a person to direct you? ___________

h.       Are you able to drive or board public service transport alone? ___________

i.         Have you been able to resume work and work in the same position you were before the illness? ___________

j.        Were you able to work the same number of hours the other people did? ___________

Category: Fun Questionnaire, Health Questionnaire

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