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Functional assessments measure a patient's ability to perform daily activities. This form covers ADL (Activities of Daily Living), IADL (Instrumental ADL), and Psychosocial domains.

  • 0 — Independent (no assistance)
  • 1 — Needs some assistance
  • 2 — Fully dependent / cannot perform

Lower total scores indicate greater independence.

  • 0–5: Minimal functional impairment
  • 6–12: Moderate functional impairment
  • 13+: Severe functional impairment

CCM patients should receive a full functional assessment at enrollment and every 6 months thereafter, or after any significant health change or hospitalization.

Functional Assessment
Sarah Johnson · Last completed: Mar 20, 2026
7
Total Score (0–38)
▲ +2 from previous (5)
Moderate
Functional Status
Previous: Minimal
Mar 20
Assessment Date
Dr. A. Kumar
ADL — Activities of Daily Living (Score: 3 / 12 · 6 items × 0–2)
Bathing
Ability to bathe without assistance
Dressing
Getting dressed independently
Toileting
Using bathroom independently
Transferring
Moving from bed/chair without help
Continence
Bladder / bowel control
Feeding
Eating without assistance
IADL — Instrumental Activities of Daily Living (Score: 3 / 16 · 8 items × 0–2)
Using Telephone
Ability to operate telephone independently
Shopping
Grocery shopping independently
Food Preparation
Preparing own meals
Housekeeping
Maintaining home environment
Laundry
Washing and folding clothes
Transportation
Traveling independently
Medications
Managing own medications
Finances
Managing bills and finances
Psychosocial Assessment (Score: 1 / 10 · 5 items × 0–2)
Social Isolation
Frequency of meaningful social contact
Emotional Wellbeing
General mood and emotional stability
Caregiver Stress
Caregiver burden assessment
Safety at Home
Risk of falls, environmental hazards
Cognitive Function
Memory, orientation, decision-making
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