FUNCTIONAL ASSESSMENT
2.1. How did the Client come to the centre?
Without walking aid With walking aid What kind? ______Wheelchair Carried
2.2. Does the lower limb problem cause difficulties in daily activities, work, school, leisure and sport?
- Is the Client able to carry out daily activities by himself?
Washing yourself 0 1 2 3 4 5 Comment? ______
Dressing 0 1 2 3 4 5 Comment? ______
Eating 0 1 2 3 4 5 Comment? ______
Toilet use0 1 2 3 4 5 Comment? ______
- Is the Client able to carry out domestic tasks?
Clean the house0 1 2 3 4 5 Comment? ______
Wash clothes0 1 2 3 4 5 Comment? ______
Cut wood0 1 2 3 4 5 Comment? ______
Make fire to cook0 1 2 3 4 5 Comment? ______
Cooking 0 1 2 3 4 5 Comment? ______
- Is the Client able to pick-up an item from the ground and lay it down on the table?
0 1 2 3 4 5 Comment? ______
- Is the Client able to pick-up and carry heavy loads by himself?
No Yes + 5 Kg + 10 Kg + 20 Kg
- Is the Client able to ride (drive) alone?
A bike0 1 2 3 4 5 Comment? ______
A motorbike 0 1 2 3 4 5 Comment? ______
A ox-cart0 1 2 3 4 5 Comment? ______
A small boat 0 1 2 3 4 5 Comment? ______
A car 0 1 2 3 4 5 Comment? ______
- Is the Client able to carry out professional activities?
Farming
- Plough a field 0 1 2 3 4 5 Comment? ______
- Plant the rice 0 1 2 3 4 5 Comment? ______
- Cut the rice 0 1 2 3 4 5 Comment? ______
Office working 0 1 2 3 4 5 Comment? ______
Others: ______
- Is the Client able to practice sports?
Volleyball 0 1 2 3 4 5 Comment? ______
Basket ball 0 1 2 3 4 5 Comment? ______
Football 0 1 2 3 4 5 Comment? ______
Boxing 0 1 2 3 4 5 Comment? ______
Others: ______
2.3. Accessibilities to facilities?
Distance house / drinking water source :- 10 m - 50 m + de 50 m
Distance house / school:- 500 m - 3 Km + de 3 Km
Distance house / local market: - 500 m - 3 Km + de 3 Km
Distance house / transport facilities:- 500 m - 3 Km + de 3 Km
Distance house / health centre: - 500 m - 3 Km + de 3 Km
Distance house / pagoda:- 500 m - 3 Km + de 3 Km
Distance house / Villageoffice:- 500 m - 3 Km + de 3 Km
Distance house / Communeoffice:- 500 m - 3 Km + de 3 Km
Summary of functional impairment activities. It will help the Interdisciplinary team to determine the treatment objectives in order to improve the Client’s functional capacity
1°2°
3°
4°
5°
Functional Impact Assessment:
Treatment objectives in order to Follow Up the improving of the Client functional capabilities:
LONG TERM GOAL of the client?Loss functionality collected in the point 2. FUNCTIONAL ACTIVITIES ASSESSMENT (page 2) / For Physio in the Centre
Client is able to do this activity at the end of the treatment: Date …../.…./….…. / For SW in the field
Client is able to do this activity after a few weeks using device: Date ../…../.….
1° / 0 1 2 3 4 5 / 0 1 2 3 4 5
2° / 0 1 2 3 4 5 / 0 1 2 3 4 5
3° / 0 1 2 3 4 5 / 0 1 2 3 4 5
4° / 0 1 2 3 4 5 / 0 1 2 3 4 5
5° / 0 1 2 3 4 5 / 0 1 2 3 4 5
Mobility impact assessment:
1° Date: ……/……/………
1° Moving limited in the bed: 0 1 2 3 4 5 Comment? ______
2° Moving in the house:0 1 2 3 4 5 Comment? ______
3° Moving around the house: 0 1 2 3 4 5 Comment? ______
4° Moving around in the village: 0 1 2 3 4 5 Comment? ______
5° Moving long distance: 0 1 2 3 4 5 Comment? ______
2° Date: ……../……./……..
1° Moving limited in the bed: 0 1 2 3 4 5 Comment? ______
2° Moving in the house:0 1 2 3 4 5 Comment? ______
3° Moving around the house: 0 1 2 3 4 5 Comment? ______
4° Moving around in the village: 0 1 2 3 4 5 Comment? ______
5° Moving long distance: 0 1 2 3 4 5 Comment? ______