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FUNCTIONAL ASSESSMENT
Client __________________________________________
0 = No Impairment
Date _____/_____/_____
1 = Minimally Impaired
Prepared by _________________________________
2 = Moderately Impaired
3 = Very Impaired
COGNITIVE STATUS
0 1 2
3
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Orientation to person, place, time |
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MEMORY |
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- Short term |
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- Long term |
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- Retention, recall |
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COMMUNICATION |
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- Attention |
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- Comprehension |
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- Oral/sign |
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- Reading |
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- Writing |
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MENTAL HEALTH |
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- Mood/affect (eg, depression, mania, control of emotions) |
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- Thought (reality testing, delusions, hallucinations) |
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- Responsiveness/compliance to psychoactive medication |
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Misuse of drugs/alcohol |
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Behavior - (wandering, assaultive, demanding, abusive) |
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Judgement/insight - to evaluate consequences of own action |
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Problem solving skills |
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Social awareness |
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Danger to self or others |
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Calculation |
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Planning and organization skills |
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Appearance |
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PERSONAL CARE
0 1 2
3
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Eating |
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Bathing |
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Dressing |
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Cooking |
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Laundry |
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Personal hygiene |
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Toileting |
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Transferring (out of bed, out of chair, etc) |
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Medication Management |
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HEALTH
0 1 2 3
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General condition |
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Ambulation |
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Mobility |
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Hearing |
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Vision |
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Dental |
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Sleep |
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Dietary Restrictions |
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Appetite |
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Need for artificial feeding/hydration |
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Bowel/bladder control |
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Skin care issues |
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COMMUNITY LIVING
0 1 2 3
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Housekeeping |
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Laundry |
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Shopping |
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TRANSPORTATION |
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- Driving |
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- Bus |
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- Ability to ride in a car |
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FINANCIAL MANAGEMENT |
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- Willingness and ability to spend necessary money |
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- Susceptibility to financial chicanery/credit abuse |
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- Ability to write checks, keep register |
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- Ability to manage investments |
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Housing and property management |
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Medical care - ability to recognize and seek care of medical needs |
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SOCIAL ABILITIES |
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- Ability to manage community interaction (eg, clerks, bus drivers) |
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- Ability to maintain friendships |
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- Ability to interact with family |
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Interest in daily mail |
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Telephone use |
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SOCIAL SUPPORTS |
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- Available and adequate family support |
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- Availability of adequate social services |
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- Adequacy of physical environment (privacy, esthetics, etc) |
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- Adequacy of finances |
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