The Patient Specific Functional Scale

I’m going to ask you to identify 3 to 5 important activities that you are unable to do or are having difficulties with as a result of your ____ problem.

Today, are there any activities that you are unable to do or have difficulties with because of your injury or problem?

Name

First Name

Last Name

Date of Birth

YYYY

Meaningful Goals / Activities

Please list 3 to 5 activities that are meaningful to you that you are struggling to do as a result of your problem. Please be as specific as you can. e.g. rather than just writing 'running' as your activity limitation, you might want to write something like 'Running a 5km trail run'. Please also rate your ability to perform each activity out of 10 using the scale above.

The Patient Specific Functional Scale

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