Template library · Assessments & screeners
Functional Pain & Disability Assessment template
Evaluate how pain affects the client's ability to perform daily activities.
Assessment of pain-related functional limitation
- 17 fields across 3 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Functional Limitation
- 1. Personal care (washing, dressing)Choice
- 2. LiftingChoice
- 3. WalkingChoice
- 4. SittingChoice
- 5. StandingChoice
- 6. SleepingChoice
- 7. Social lifeChoice
- 8. TravelingChoice
- 9. Employment / household dutiesChoice
- 0-20% — Minimal disability: Routine management
- 21-40% — Moderate disability: Consider multidisciplinary referral
- 41-60% — Severe disability: Comprehensive pain management program
- 61%+ — Crippling / bed-bound: Urgent comprehensive evaluation
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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