231 (231)    MH REPORT (601.93)

|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.>)