Functional Screening Examination
| Test Request | Function Tested | Able Normal | Limited but Able | Unable |
| Put both hands together, behind your head | Shoulder external rotation, flexion, abduction; elbow flexion; wrist extension; gross strength (managing clothing, hair combing, washing back) | □ | □ | □ |
| Put both hands together, behind your back | Shoulder internal rotation, adduction; elbow flexion; gross strength (managing clothing, washing lower back) | □ | □ | □ |
| Sitting, touch great toe with opposite hand | Back, hip, knee flexion, gross strength, balance (lower extremity dressing and hygiene) | □ | □ | □ |
| Squeeze my two fingers, each hand | Grasp; approximately 20 lb grasp needed for functional activities (e.g., holding a pan) | □ | □ | □ |
| Hold paper between thumb and lateral side of index finger (while examiner tries to pull it out) | Pinch; approximately. 3 lb grip needed for functional activities (e.g., turning a key) | □ | □ | □ |
| Show me your medicines | Cognition; knowledge; visual acuity, hand function; compliance; polypharmacy; effective management of health problems; access to health care; support system; finances; polyproviders | □ | □ | □ |
| Get up from the chair without using your hands, walk 10 ft down hall, turn around, stand with your eyes closed (examiner nudges to determine balance), sit down without using hands | Hip strength; gait, symmetry in posture velocity, step height; balance, ability to withstand sudden changes in position; fall risk; cardiovascular and pulmonary status; transfer ability; motion; fear of falls; judgment and cognition; environmental awareness; need for assistance/equipment; flexibility; endurance; ability to walk and function at home | □ | □ | □ |
| Take off your shoes and socks | Balance; fine motor skills; dexterity; hearing and receptive language; visual acuity; judgment; registration and attention span; low back flexibility and mobility; weight shifting; safety and adequacy of footware; social support if nails are cut by someone else; pain and comfort on movement | '□ | □ | □ |
| Observe a meal being prepared/eaten | Nutritional intake; intactness of reflexes; use of utensils; hand/oral motor function; sequencing skills, visual acuity; use of utensils and equipment; ability to get needed help; ability to handle food and liquid; ability to compensate for limitations | □ | □ | □ |
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Summary and conclusions:
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