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Applicant Name:			File No.:
	Note performance without help		Note degree of assistance
	With ease, no devices, no prior preparation	With difficulty, or with device or prior preparation	Some help	Totally dependent
Feed/Drink
Dress Upper body
Dress Lower Body
Don Brace/ Prosthesis
Wash/Bathe
Perineum (at toilet)
Sphincters Control	Note control without help:		Note frequency of accidents:
	Complete, voluntary	Control, but with urgency, or use of cath, appl, supp.	Occasional, some help needed	Frequent or much wet/soil
Bladder Control
Bowel Control
Mobility/ Locomotion	With ease, no devices, no prior preparation	With difficulty, or with device or prior preparation	Some help	Totally dependent
Transfer Bed
Transfer
Chair/Wheelchair
Transfer Toilet
Transfer Tub/Shower
Transfer Automobile
Walk 50 yards – Level
Stairs, Up/Down 1 floor
Walk Outdoors – 50 yards
Wheelchair – 50 yards
N.B. In the context of the functional assessment, devices include such things as feeding cuffs, special cutlery/dishes, dressing aides, transfer boards/poles.
Communication	Full	Moderate	Minimal	Null
Comprehension
Expression
Social Cognition
Social Interaction
Memory
Conclusion	Intact	Limited	Helper	Null
Self-Care
Current residence
Own Home	Relative’s home	Personal care Home	Hospital	Other (specify)

Time at above: ______ years _____ months

______________________
Current Caregiver

______________________
Designation

____________________________
Signature of Examining Physician

_____________________
Date: Day/Month /Year

(99-11-25)