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Run: Patient-Specific Functional Scale (PSFS)

Track a patient’s own functional goals with a PSFS form that records chosen activities and 0–10 difficulty scores over time. Use it to capture meaningful cha...

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Submission Details

Assessment date (required)

Select the date this PSFS was completed.

Assessment interval (required)

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 (required)

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 (required)

I understand that my responses will be used to track functional progress over time and may be added to my health record.

Yes No N/A

Anonymous submission

Select only if this form is being used outside the patient record and you do not want identifying information stored.

Yes No N/A

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Email (required)

Your name (optional)

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