Instructions: Please identify up to three important activities that you are unable to do or are having difficulty with as a result of your injury or problem. Today, are there any activities that you are unable to do or having difficulty with because of your injury or problem? 

0= unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
0= unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
0= unable to perform activity // 10 = able to perform activity at the same level as before injury or problem
Name *
Name
Date *
Date

PSFS developed by: Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada, 47, 258-263.