Applying Functional Medicine in Clinical Practice
PATIENT DAILY ACTIVITY SCHEDULE
(Subjective Functional Capacity)
NAME ____________________________________________ DATE ______________________
Please circle the one best response for each activity described below:
Activities of Daily Living (bathing, dressing, feeding self, toilet)
1. Need some assistance
2. Slight difficulty
3. Minimal difficulty
4. No problem
Laundry
1. Unable
2. Occasionally
3. Regularly in small steps or with help
4. Regularly without help
Cooking
1. Unable
2. Take-out, breakfast, or simple lunch only
3. Simple microwave or crockpot meal
4. Regular meals
Housekeeping
1. Unable
2. Light dusting, straighten up
3. Regular housekeeping in small steps or with help
4. Regular
Grocery Shopping
1. Unable
2. Occasional (once or twice per month)
3. Frequent, but with assistance
4. No problem
Social Activities (church, temple, family and friends)
1. Unable
2. Infrequently
3. Occasionally (once or twice per month)
4. Frequently (weekly or more often)
Driving
1. Unable
2. Very limited
3. Cautious, local trips
4. Distant trips or traffic
Errands or Light Chores (examples: post office, drop off a child)
1. None
2. 0-1 per day
3. 2-3 per day
4. No or few restrictions
Score:_____________