FUNCTIONAL INFORMATION – Spinal Cord Injury
To be completed by Allied Health Team
Patient’s Name:
Cause of injury:
Premorbid function:
Independent in ADL
Dependent in ADL
Comments: ______________________________________________________________________________________________________________
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Self Care:
Dressing:
Independent
Total assistance
Partial assistance Supervision only
Bathing:
Independent
Total assistance
Partial assistance Supervision only
Comments: ______________________________________________________________________________________________________________
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Swallowing:
Intact, regular diet
Dental soft diet
Minced diet
Pureed diet
Thickened fluids
Comments: ______________________________________________________________________________________________________________
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Feeding:
Independent
Supervision required Partial assistance Total assistance Tube feed
Comments: ______________________________________________________________________________________________________________
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Transfers:
Mechanical lift
2 person
1 person
Supervision only Independent
On bed rest
Comments: ______________________________________________________________________________________________________________
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Mobility aide:
Standard Walker
Rollator
Wheelchair
Cane
Crutches
2 Wheeled Walker
Other (specify)
Comments: ______________________________________________________________________________________________________________
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Wheelchair:
Requirements
Manual
Manual with tilt
Power
Power with tilt
Dimensions
Hip width
Upper leg length
Lower leg length
Ambulation:
Non-ambulatory
2 person
1 person
Supervision only Independent
Distance (specify) ________________________
Comments: ______________________________________________________________________________________________________________
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Limbs:
Normal
Left sided impairment Right sided impairment
Bilateral impairment
U/E impairment
L/E impairment
Impaired coordination
Reduced strength
Other ________________________________________________________________________________________________
Comments: ______________________________________________________________________________________________________________
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Spinal Cord Injury Functional Section / December 2011
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