Patient-Specific Functional Scale (PSFS)

A patient-reported outcomes form to document individualized functional activities and rate difficulty or performance on a 0–10 scale over time.

Submission Details

• Assessment date
  Select the date this PSFS was completed.
• Assessment interval
  Choose whether this is the baseline or a follow-up measurement.
• Interval notes
  Optional brief note if this assessment is being completed at another interval.

Patient-Identified Activities

• Functional activities
  List up to 5 patient-identified activities. Use one row per activity, such as lifting, sleeping, walking, or reaching.

Scoring Guidance

• Scoring instruction
• Low anchor
• High anchor

Patient Consent and Submission

• Consent acknowledgement
  I understand that my responses will be used to track functional progress over time and may be added to my health record.
• Anonymous submission
  Select only if this form is being used outside the patient record and you do not want identifying information stored.