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Run: Patient-Specific Functional Scale (PSFS)

The Patient-Specific Functional Scale (PSFS) template captures the activities a patient says matter most, then tracks each one with a 0–10 rating over time. ...

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Assessment Details

Assessment Date (required)

Visit Type (required)

Clinician Name (required)

Patient Identifier (required)

Use the local medical record number or other internal identifier. Do not enter SSN or other unnecessary PII.

Patient-Identified Functional Activities

Functional Activities (required)

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

Activity Ratings

Activity Rating Table (required)

Clinical Notes and Consent

Clinical Notes

Consent and Disclosure Acknowledgement (required)

I understand this information will be used for clinical care, outcome tracking, and documentation in the patient's record.

Yes No N/A

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