Functional Ability Questionnaire

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Ageless Fitness is tailored to your needs. To help us qualify you, please rate your current ability for various activities on a scale of 1 (Not at all) to 10 (Optimal) and complete a brief summary for each question listed at the bottom.

Name

Date

YYYY

Phone Number

Ability Rating (scroll left/right to see all ratings)

1 (Not at all)

2 (Very poor)

3 (Poor)

4 (Fair)

5 (Average)

6 (Above average)

7 (Good)

8 (Very good)

9 (Excellent)

10 (Optimal)

Walking

Getting up and down off the ground

Touching the ground

Going up and down stairs

Getting out of bed

Getting out of a standard chair

Dressing - shirt, pants, tie shoes

Loading, unloading, carrying groceries

Reaching overhead (top shelf)

Using a step stool or ladder

Overall balance + stability

Housework (cooking, cleaning, yard work, etc.)

1 (Not at all)

2 (Very poor)

3 (Poor)

4 (Fair)

5 (Average)

6 (Above average)

7 (Good)

8 (Very good)

9 (Excellent)

10 (Optimal)

Walking

Getting up and down off the ground

Touching the ground

Going up and down stairs

Getting out of bed

Getting out of a standard chair

Dressing - shirt, pants, tie shoes

Loading, unloading, carrying groceries

Reaching overhead (top shelf)

Using a step stool or ladder

Overall balance + stability

Housework (cooking, cleaning, yard work, etc.)

Clear selection

Primary Goal

Health Conditions

Movement Limitations

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