Functional Assessment Form

About this form

The functional assessment form is a clinical & charting document used by physical therapy practices. Functional assessment including ADLs, pain scale, and movement limitations. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 10 fields:

• Patient Name — Text
• Current pain level — Single choice
• Activities currently limited — Multiple choice
• What makes the pain worse? — Long answer
• What makes the pain better? — Long answer
• Goals for therapy — Text
• Use of assistive device? — Single choice
• Other limitations — Long answer
• Signature — Signature
• Date — Date

When practices use it

Physical Therapy teams typically attach this form to the day-to-day office workflow. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.