Functional Skills Checklist

Patient Name: ________________________

Dates Completed: ___________________________________

Functional Tasks:
Self Care:
Functional Level/Date:
___________ _____ Sponge bathe including retrieval of supplies
___________ _____ Transfer in/out of shower
___________ _____ Showering seated or standing
___________ _____ Total body dressing
___________ _____ Toilet transfer Device: ____________
___________ _____ Toilet hygiene, clothing management
___________ _____ Oral hygiene, washing hands/face
___________ _____ Bed mobility during self care tasks

Home Safety & Management:

Functional Level/Date:
___________ _____ Open/Close refrigerator/freezer to retrieve items
___________ _____ Transport items to counter
___________ _____ Fill pot with water, carry to stove
___________ _____ Turn stove on, manage temperature, turn stove off
___________ _____ Turn oven on, manage temperature, remove item
___________ _____ Turn sink faucet on/off. Identify hot/cold water
___________ _____ Operate coffee maker to make coffee
___________ _____ Pour hot coffee into a coffee mug
___________ _____ Transport a cup of coffee, plate of food to the table
___________ _____ Retrieve supplies, make a sandwich
___________ _____ Read directions for a microwave meal, cook meal
___________ _____ Recall the phone number for emergency services
___________ _____ Use phone to make a call or text
___________ _____ Identify staged unsafe situations in kitchen
___________ _____ Wash and dry dishes standing at sink
___________ _____ Load/Unload dishwasher
__________ _____ Complete a menu for 3 meals/day for 7 days
Functional Level/Date:
___________ _____ Call pharmacy to refill prescriptions
___________ _____ Manage medications, take pills at appropriate time
___________ _____ Fill pot of with water, carry to stove
___________ _____ Make their bed.
___________ _____ Write out a check to pay bills, manage checkbook
___________ _____ Iron clothes in standing
___________ _____ Hang up clothing in closet
___________ _____ __________________________________
___________ _____ __________________________________
___________ _____ __________________________________
___________ _____ __________________________________
___________ _____ __________________________________

Recommend Assistance With:

______________________________________________________
______________________________________________________
______________________________________________________

Comments:
______________________________________________________
______________________________________________________
______________________________________________________

Recommended Equipment:
______________________________________________________
______________________________________________________

Therapist: ______________________________ Date: __________

 Functional Skills Checklist

Mrs. Smile
Patient Name: ________________________
5/22/23; 5/25/23; 5/28/23; 5/31/23; 6/1/23;
Dates Completed: ___________________________________

Functional Tasks:
Self Care:
Functional Level/Date:
___________
Independent _____
5/22/23 Sponge bathe including retrieval of supplies
___________
Supervision _____
5/25/23 Transfer in/out of shower
___________
Supervision _____
5/25/23 Showering seated or standing
___________
Supervision _____
5/25/23 Total body dressing
___________
Independent 5/22/23
_____ Toilet transfer Device: ____________
Rolling Walker
___________
Independent _____
5/22/23 Toilet hygiene, clothing management
Independent
___________ _____
5/22/23 Oral hygiene, washing hands/face
Independent
___________ 5/22/23
_____ Bed mobility during self care tasks

Home Safety & Management:

Functional Level/Date:
___________
Supervision _____
5/28/23 Open/Close refrigerator/freezer to retrieve items
___________
Supervision 5/28/23
_____ Transport items to counter
___________
Total A/Unable _____
5/28/23 Fill pot with water, carry to stove
___________
Min Assist _____
5/28/23 Turn stove on, manage temperature, turn stove off
___________
Max Assist _____
5/28/23 Turn oven on, manage temperature, remove item
___________
Supervision _____
5/28/23 Turn sink faucet on/off. Identify hot/cold water
___________
Moderate Assist _____
5/28/23 Operate coffee maker to make coffee
___________
Supervision 5/28/23
_____ Pour hot coffee into a coffee mug
___________
Supervision _____
5/28/23 Transport a cup of coffee, plate of food to the table
Independent
___________ 5/31/23
_____ Retrieve supplies, make a sandwich
___________
Independent _____
5/31/23 Read directions for a microwave meal, cook meal
___________
Unable _____
5/31/23 Recall the phone number for emergency services
___________
Supervision _____
5/31/23 Use phone to make a call or text
___________
Not Tested _____ Identify staged unsafe situations in kitchen
Supervision
___________ _____
5/31/23 Wash and dry dishes standing at sink
Not Tested
___________ _____ Load/Unload dishwasher
__________
Min Assist _____
5/31/23 Complete a menu for 3 meals/day for 7 days
Functional Level/Date:
___________
Independent _____
5/28/23 Call pharmacy to refill prescriptions
___________
Supervision _____
6/1/23 Fill pill box, take pills at appropriate time
Independent
___________ _____
6/1/23 Make their bed.
Supervision
___________ _____
6/1/23 Write out a check to pay bills, manage checkbook
___________
Not Tested _____ Iron clothes in standing
___________
Independent _____
6/1/23 Hang up clothing in closet
___________
Max Assist _____
6/1/23 __________________________________
Carry bags of groceries up stairs to enter house
___________
Total Assist _____
6/1/23 Check blood sugar, administer insulin
__________________________________
___________
Supervision _____
6/1/23 Sweep and vacuum floor
__________________________________
___________
Supervision _____
6/1/23 Remove dirty sheets on bed replace with clean ones
__________________________________
___________
Supervision _____
6/1/23 __________________________________
Wash windows in standing

Recommend Assistance With:

Meal preparation including use of stove/oven; making coffee; supervision showering;
______________________________________________________
Setting up pill box; Monitor for compliance to prescribed medication schedule.
____________________________________________________
Assist with transportation to get groceries;
______________________________________________________

Comments:
______________________________________________________
Recommend trialing food delivery service for microwave meals
______________________________________________________
Make list of important phone numbers and place my telephone in house
______________________________________________________
Recommend patient not use stove/oven unless supervised

Recommended Equipment:
Medical Alert Necklace; Rolling Walker; Railings on Stairs; Shower Bench.
______________________________________________________
______________________________________________________

Therapist Signature
Therapist: ______________________________ Date: __________