Patient Specific Functional Scale

This useful questionnaire can be used to quantify activity limitation and measure functional outcome for clients with any orthopaedic condition.

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* 1. Client name: Surname, First Name

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* 2. Who is your Physiotherapist?

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* 3. Please list up to 3 important activities that you are unable to do or are having difficulty performing as a result of your neck pain.

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* 4. Please rate how difficult each activity is on a scale of 0 (unable to perform the activity) to 10 (able to perform activity at the same level as before injury or problem).

  unable to perform activity 0 1 2 3 4 5 6 7 8 9 able to perform activity at same level as before injury or problem 10
Activity 1:
Activity 2:
Activity 3:

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* 5. Interpretation of scores (for office use only)

Total Score: sum of activity scores _____ / number of activities _____ = ________          MDC (chronic pain) = 2                SCORE RANGE = 0 (max disability) to 10 (no disability)

PSFS developed by: Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual
patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263.

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