| RPT |
|Post-COVID-19 Functional Status Scale (PCFS)
| Gender: <.Patient_Gender.>
|
| PCFS Scale Grade = <-PCFS->
|
| Grade 0 = No functional limitations
| Grade 1 = Negligible functional limitations
| Grade 2 = Slight functional limitations
| Grade 3 = Moderate functional limitations
| Grade 4 = Severe functional limitations
|
|
|Questions and Answers:
|
| 1. Can you live alone without any assistance from another person?
| (e.g. independently being able to eat, walk, use the toilet and
| manage routine daily hygiene)
| <*Answer_9055*>
| 2. Are there duties/activities at home or at work which you are no
| longer able to perform yourself?
| <*Answer_9056*>
| 3. Do you suffer from symptoms, pain, depression or anxiety?
| Date Given: <.Date_Given.>
| <*Answer_9057*>
| 4. Do you need to avoid or reduce duties/activities or spread these
| over time?
| <*Answer_9058*>
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Clinician: <.Staff_Ordered_By.>
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
