Patient Questionnaire
Holsman Physical Therapy & Wellness · NJ & NYC clinics + in-home therapy
holsmanwellness.com · 1-855-465-7626
Holsman Physical Therapy & Wellness · NJ & NYC clinics + in-home therapy
holsmanwellness.com · 1-855-465-7626
Rate up to 5 activities that matter to you, from 0 to 10.
The Patient-Specific Functional Scale (PSFS) asks you to name up to 5 important activities your problem makes hard, then rate how well you can do each one from 0 to 10. Physical therapists use it with almost any condition to measure function and track progress on the things that matter to you. It takes about 3 minutes.
You can fill this in yourself; your therapist reviews it with you. If you have chest pain, sudden weakness or trouble breathing, call 911.
Instructions
Identify up to 5 important activities that you are unable to do or are having difficulty with as a result of your problem. For each one, choose the number that best describes your ability to do it today.
At a follow-up, rate the same activities again so the scores can be compared.
This is a questionnaire, not a diagnosis. The PSFS shows how your problem affects the activities you chose. It can’t tell you what is causing it or what treatment you need, and scores can’t be compared between people because everyone picks different activities. Review your result with your therapist, your doctor or another licensed health care provider.
Sources. Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a report of a patient specific measure. Physiotherapy Canada. 1995;47:258-263. Scoring and detectable change values as printed on the Shirley Ryan AbilityLab RehabMeasures PSFS form. Horn KK, Jennings S, Richardson G, et al. The Patient-Specific Functional Scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42(1):30-42.
© 1995, P. Stratford, reprinted with permission.
Clinically reviewed by Dr. Richard Holsman, PT, DPT, NCS. Last reviewed: November 14, 2026. Holsman Physical Therapy is not affiliated with these authors, organizations or journals, and they do not endorse this website.
Next step: Bring this printout to your next visit and review it with your therapist. Holsman physical therapists see patients at clinics across North Jersey, the Bronx and Brooklyn, plus in-home visits. Refer a patient or call 1-855-465-7626.
The PSFS is a short self-report measure developed by Paul Stratford and colleagues in 1995. You name up to 5 important activities that your problem makes hard and rate each from 0 (unable to perform) to 10 (able to perform at the same level as before the injury or problem).
Add the activity scores and divide by the number of activities. The result runs from 0 to 10, and higher scores mean better function.
The minimum detectable change at 90% confidence is 2 points for the average score and 3 points for a single activity. Changes smaller than that may be normal variation.
Choose activities that are important to you and that your problem makes hard, such as climbing stairs, lifting a grandchild, sleeping through the night or going for a walk. At follow-up visits, rate the same activities again.
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Physical therapists at clinics across North Jersey, the Bronx and Brooklyn, plus in-home visits.
📞 Call 1-855-465-7626