Patient-Specific Functional Scale (PSFS)

A clinical form for documenting patient-identified functional activities and rating each activity from 0 to 10 over time to track progress toward individualized goals.

Assessment Details

• Assessment Date
• Visit Type
• Clinician Name
• Patient Identifier
  Use the local medical record number or other internal identifier. Do not enter SSN or other unnecessary PII.

Patient-Identified Functional Activities

• Functional Activities
  Enter each patient-identified activity as a separate item, such as lifting, sleeping, walking, or reaching.

Activity Ratings

• Activity Rating Table

Clinical Notes and Consent

• Clinical Notes
• Consent and Disclosure Acknowledgement
  I understand this information will be used for clinical care, outcome tracking, and documentation in the patient's record.