Guide to Functional Assessment Screening
Functional Assessment Sample Questions
Component
Vision Do you have any difficulty
seeing? Do you wear glasses
or contact lenses? Do you
use any special equipment to
help you see, such as a high-
intensity light or magnifying
glass? When was your last
eye exam?
Hearing Do you have difficulty
hearing? Does anyone tell
you that you are hard of
hearing? Do you have to ask
people to repeat what they
say? Can you hear well in
crowds? Can you hear when
the area is noisy?
Mobility Do you have any trouble
moving? Do you feel steady
when you walk? Do you use
anything to help you walk?
Do you have trouble getting
out of bed? Do you have
difficulty sitting down or
standing up?
Fall history Have you had any falls? Have
you had any near falls? Do
you take any precautions
against falling?
Continence Do you ever lose control of
your bowels? Do you ever
lose control of your urine and
Observations/Examinations
Observe for signs of impaired
vision during interaction with
patient: turning head to one
side in an effort to see better;
nonapplicable comments about
room seeming dark; feeling for
items. Have patient hold a
magazine or newspaper and
read a line of print. Have
patient read a wall clock or sign
at a distance.
Note patient's apparent
hearing during your interaction
with him or her. Rub your
thumb and forefinger together
in front of each of patient's
ears; patient should easily hear
the sound.
Observe patient's general
movements; look for obvious
limitation of movement in any
body part. Have patient put
hands together behind neck
and then behind waist to
assess external and internal
rotation of shoulder. Assess
lower extremity function,
balance, and gait by asking
patient to arise from a straight
back chair, stand still, walk
across room (approximately 10
feet), turn, walk back, and sit
down. Note ability to stand up
and sit down; balance when
sitting, standing, and walking;
gait; and ability to turn.
 wet yourself? Do you wear
any type of protective pad or
underclothes in case of an
accident with urine or
bowels?
Nutrition Have you gained or lost 10 Note general appearance as
pounds in the past 6 months related to nutritional status:
without trying? What do you well nourished,
typically eat in a day? Do you undernourished, emaciated.
have difficulty chewing or Obtain weight and determine
swallowing? When was your body mass index.
last dental visit?
Cognition Do you have any trouble with Note patient's ability to
your memory? respond appropriately to
questions and directions.
Three-item recall at 1 minute;
if patient fails this test, follow
with MMSE.
Affect Do you often feel anxious or Note patient's expression and if
overstressed? Do you often this matches mood.
feel sad or down?
Home environment Who do you live with? What
type of house do you have:
single home, multiple family,
apartment? How many floors
does the home have? Are
there stairs you must use?
Social participation What keeps you busy all day?
How often do you go out?
How often do you have
company?
Activities of Daily Living Use a reliable, valid
(basic and instrumental) assessment tool to assess
function related to grooming,
toileting, dressing, eating,
walking, shopping, meal
preparation, housekeeping,
travel/driving, money
management.
MMSE, Mini-Mental Status Examination.