ICF CHECKLIST
Version 2.1a, Clinician Form
for International Classification of Functioning, Disability and Health
This is a checklist of major categories of the International Classification of Functioning, Disability and Health (ICF) of the World Health Organization . The ICF Checklist is a practical tool to elicit and record information on the functioning and disability of an individual. This information can be summarized for case records (for example, in clinical practice or social work). The checklist should be used along with the ICF or ICF Pocket version.
H 1. When completing this checklist, use all information available. Please check those used:
[1] written records |
[2] primary respondent |
[3] other informants |
[4] direct observation |
If medical and diagnostic information is not available it is suggested to complete |
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appendix 1: Brief Health Information (p 9-10) which can be completed by the respondent. |
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H 2. Date __ __ /__ __/ __ __ |
H 3. Case ID _ _ , __ __ __ , __ H 4. Participant No. __ __ , __ __ , __ __ __ |
Day Month |
Year |
CE or CS |
Case No. 1st or 2nd Evalu |
FTC |
Site Participant |
A.DEMOGRAPHIC INFORMATION
A.1 NAME (optional) |
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First ____________________ |
FAMILY_______________________ |
A.2 SEX |
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(1) [ |
] Female |
(2) [ |
] Male |
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A.3 DATE OF BIRTH _ _/_ _/_ _ |
(date/month/year) |
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A.4 ADDRESS (optional) |
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A.5 YEARS OF FORMAL EDUCATION |
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A.6 CURRENT MARITAL STATUS: (Check only one that is most applicable) |
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(1) |
Never married |
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(4) Divorced |
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(2) |
Currently Married |
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(5) Widowed |
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(3) |
Separated |
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(6) Cohabiting |
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A.7 CURRENT OCCUPATION (Select the single best option) |
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(1) Paid employment |
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(6) |
Retired |
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(2) |
Self-employed |
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(7) |
Unemployed (health reason) |
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(3) |
Non-paid work, such as volunteer/charity |
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(8) |
Unemployed (other reason) |
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(4) |
Student |
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(9) |
Other |
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(5) |
Keeping house/House-maker |
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[ ] |
(please specify) ____________ |
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A.8 MEDICAL DIAGNOSIS of existing Main Health Conditions, |
if possible give ICD Codes. |
1.No Medical Condition exists
2. |
…………………….. |
ICD code: __. __. __.__. __ |
3. |
…………………….. |
ICD code: __. __. __.__. __ |
4. |
…………………….. |
ICD code: __. __. __.__. __ |
5. A Health Condition (disease, disorder, injury ) exists, however its nature or diagnosis is not known
ICF Checklist © World Health Organization, September 2003. |
Page 1 |
PART 1a: IMPAIRMENTS of BODY FUNCTIONS
•Body functions are the physiological functions of body systems (including psychological functions).
•Impairments are problems in body function as a significant deviation or loss.
First Qualifier: Extent of impairments
0 No impairment means the person has no problem
1 Mild impairment means a problem that is present less than 25% of the time, with an intensity a person can tolerate and which happens rarely over the last 30 days.
2 Moderate impairment means that a problem that is present less than 50% of the time, with an intensity, which is interfering in the persons day to day life and which happens occasionally over the last 30 days.
3 Severe impairment means that a problem that is present more than 50% of the time, with an intensity, which is partially disrupting the persons day to day life and which happens frequently over the last 30 days.
4 Complete impairment means that a problem that is present more than 95% of the time, with an intensity, which is totally disrupting the persons day to day life and which happens every day over the last 30 days.
8 Not specified means there is insufficient information to specify the severity of the impairment.
9 Not applicable means it is inappropriate to apply a particular code (e.g. b650 Menstruation functions for woman in pre-menarche or post-menopause age).
Short List of Body Functions |
Qualifier |
b1. MENTAL FUNCTIONS |
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b110 |
Consciousness |
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b114 |
Orientation |
(time, place, person) |
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b117 |
Intellectual |
( incl. Retardation, dementia) |
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b130 |
Energy and drive functions |
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b134 Sleep |
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b140 |
Attention |
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b144 Memory |
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b152 |
Emotional functions |
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b156 Perceptual functions |
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b164 |
Higher level cognitive functions |
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b167 |
Language |
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b2. SENSORY FUNCTIONS AND PAIN |
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b210 Seeing |
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b230 |
Hearing |
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b235 Vestibular (incl. Balance functions) |
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b280 Pain |
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b3. VOICE AND SPEECH FUNCTIONS |
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b310 Voice |
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b4. FUNCTIONS OF THE CARDIOVASCULAR, HAEMATOLOGICAL, |
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IMMUNOLOGICAL AND RESPIRATORY SYSTEMS |
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b410 Heart |
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b420 Blood pressure |
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b430 Haematological (blood) |
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b435 Immunological (allergies, hypersensitivity) |
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b440 Respiration (breathing) |
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b5. FUNCTIONS OF THE DIGESTIVE, METABOLIC AND ENDOCRINE SYSTEMS |
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b515 |
Digestive |
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b525 |
Defecation |
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b530 |
Weight maintenance |
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b555 |
Endocrine glands (hormonal changes) |
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b6. GENITOURINARY AND REPRODUCTIVE FUNCTIONS |
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b620 |
Urination functions |
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b640 Sexual functions
b7. NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTIONS
b710 Mobility of joint
b730 Muscle power
b735 Muscle tone
b765 Involuntary movements
b8. FUNCTIONS OF THE SKIN AND RELATED STRUCTURES
ANY OTHER BODY FUNCTIONS
Part 1 b: IMPAIRMENTS of BODY STRUCTURES
•Body structures are anatomical parts of the body such as organs, limbs and their components.
•Impairments are problems in structure as a significant deviation or loss.
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First Qualifier: Extent of impairment |
Second Qualifier: Nature of the change |
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0 No impairment means the person has no problem |
0 |
No change in structure |
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1 Mild impairment means a problem that is present less than 25% |
1 Total absence |
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of the time, with an intensity a person can tolerate and which |
2 |
Partial absence |
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happens rarely over the last 30 days. |
3 |
Additional part |
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2 Moderate impairment means that a problem that is present less |
4 |
Aberrant dimensions |
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than 50% of the time, with an intensity, which is interfering in the |
5 |
Discontinuity |
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persons day to day life and which happens occasionally over the |
6 |
Deviating position |
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last 30 days. |
7 |
Qualitative changes in structure, including |
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3 Severe impairment means that a problem that is present more |
accumulation of fluid |
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than 50% of the time, with an intensity, which is partially |
8 |
Not specified |
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disrupting the persons day to day life and which happens frequently |
9 |
Not applicable |
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over the last 30 days. |
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4 Complete impairment means that a problem that is present more |
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than 95% of the time, with an intensity, which is totally disrupting |
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the persons day to day life and which happens every day over the |
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last 30 days. |
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8 Not specified means there is insufficient information to specify |
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the severity of the impairment. |
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9 Not applicable means it is inappropriate to apply a particular |
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code (e.g. b650 Menstruation functions for woman in pre-menarche |
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or post-menopause age). |
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Short List of Body Structures |
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First Qualifier: |
Second Qualifier: |
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Extent of impairment |
Nature of the change |
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s1. STRUCTURE OF THE NERVOUS SYSTEM |
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s110 Brain |
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s120 Spinal cord and peripheral nerves |
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s2. THE EYE, EAR AND RELATED STRUCTURES |
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s3. STRUCTURES INVOLVED IN VOICE AND SPEECH |
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s4. STRUCTURE OF THE CARDIOVASCULAR, |
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IMMUNOLOGICAL AND RESPIRATORY SYSTEMS |
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s410 Cardiovascular system |
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s430 Respiratory system |
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s5. STRUCTURES RELATED TO THE DIGESTIVE, |
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METABOLISM AND ENDOCRINE SYSTEMS |
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ICF Checklist © World Health Organization, September 2003. |
Page 3 |
s6. STRUCTURE RELATED TO GENITOURINARY AND REPRODUCTIVE SYSTEM
s610 Urinary system
s630 Reproductive system
s7. STRUCTURE RELATED TO MOVEMENT
s710 Head and neck region
s720 Shoulder region
s730 Upper extremity (arm, hand)
s740 Pelvis
s750 Lower extremity (leg, foot)
s760 Trunk
s8. SKIN AND RELATED STRUCTURES
ANY OTHER BODY STRUCTURES
PART 2: ACTIVITY LIMITATIONS & PARTICIPATION RESTRICTION
•Activity is the execution of a task or action by an individual.. Participation is involvement in a life situation.
•Activity limitations are difficulties an individual may have in executing activities. Participation restrictions are problems an individual may have in involvement in life situations.
The Performance qualifier indicates the extent of Participation restriction by describing the persons actual performance of a task or action in his or her current environment. Because the current environment brings in the societal context, performance can also be understood as "involvement in a life situation" or "the lived experience" of people in the actual context in which they live. This context includes the environmental factors – all aspects of the physical, social and attitudinal world that can be coded using the Environmental. The Performance qualifier measures the difficulty the respondent experiences in doing things, assuming that they want to do them.
The Capacity qualifier indicates the extent of Activity limitation by describing the person ability to execute a task or an action. The Capacity qualifier focuses on limitations that are inherent or intrinsic features of the person themselves. These limitations should be direct manifestations of the respondent's health state, without the assistance. By assistance we mean the help of another person, or assistance provided by an adapted or specially designed tool or vehicle, or any form of environmental modification to a room, home, workplace etc.. The level of capacity should be judged relative to that normally expected of the person, or the person's capacity before they acquired their health condition.
Note: Use Appendix 2 if needed to elicit information on the Activities and Participation of the individual
First Qualifier: Performance
Extent of Participation Restriction
Second Qualifier: Capacity (without assistance) Extent of Activity limitation
0 No difficulty means the person has no problem
1 Mild difficulty means a problem that is present less than 25% of the time, with an intensity a person can tolerate and which happens rarely over the last 30 days.
2 Moderate difficulty means that a problem that is present less than 50% of the time, with an intensity, which is interfering in the persons day to day life and which happens occasionally over the last 30 days.
3 Severe difficulty means that a problem that is present more than 50% of the time, with an intensity, which is partially disrupting the persons day to day life and which happens frequently over the last 30 days.
4 Complete difficulty means that a problem that is present more than 95% of the time, with an intensity, which is totally disrupting the persons day to day life and which happens every day over the last 30 days.
8 Not specified means there is insufficient information to specify the severity of the difficulty.
9 Not applicable means it is inappropriate to apply a particular code (e.g. b650 Menstruation functions for woman in pre-menarche or post-menopause age).
Short List of A&P domains |
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Performance |
Capacity Qualifier |
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Qualifier |
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d1. LEARNING AND APPLYING KNOWLEDGE |
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d110 |
Watching |
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d115 |
Listening |
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d140 |
Learning to read |
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d145 |
Learning to write |
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d150 |
Learning to calculate (arithmetic) |
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d175 Solving problems |
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d2. GENERAL TASKS AND DEMANDS |
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d210 |
Undertaking a single task |
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d220 |
Undertaking multiple tasks |
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d3. COMMUNICATION |
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d310 |
Communicating with -- receiving -- |
spoken messages |
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d315 |
Communicating with -- receiving -- non-verbal messages |
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d330 Speaking |
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d335 Producing non-verbal messages |
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d350 |
Conversation |
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d4. MOBILITY |
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d430 |
Lifting and carrying objects |
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d440 Fine hand use (picking up, grasping) |
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d450 |
Walking |
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d465 Moving around using equipment (wheelchair, skates, etc.) |
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d470 |
Using transportation (car, bus, train, plane, etc.) |
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d475 |
Driving (riding bicycle and motorbike, driving car, etc.) |
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d5. SELF CARE |
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d510 Washing oneself (bathing, drying, washing hands, etc) |
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d520 |
Caring for body parts (brushing teeth, shaving, grooming, etc.) |
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d530 |
Toileting |
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d540 |
Dressing |
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d550 |
Eating |
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d560 |
Drinking |
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d570 |
Looking after one`s health |
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d6. DOMESTIC LIFE |
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d620 |
Acquisition of goods and services (shopping, etc.) |
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d630 Preparation of meals (cooking etc.) |
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d640 |
Doing housework (cleaning house, washing dishes laundry, ironing, etc.) |
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d660 |
Assisting others |
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d7. INTERPERSONAL INTERACTIONS AND RELATIONSHIPS |
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d710 |
Basic interpersonal interactions |
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d720 |
Complex interpersonal interactions |
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d730 |
Relating with strangers |
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d740 Formal relationships |
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d750 |
Informal social relationships |
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d760 Family relationships |
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d770 |
Intimate relationships |
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d8. MAJOR LIFE AREAS |
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ICF Checklist © World Health Organization, September 2003. |
Page 5 |
d810 Informal education
d820 School education
d830 Higher education
d850 Remunerative employment
d860 Basic economic transactions
d870 Economic self-sufficiency
d9. COMMUNITY, SOCIAL AND CIVIC LIFE
d910 Community Life
d920 Recreation and leisure
d930 Religion and spirituality
d940 Human rights
d950 Political life and citizenship
ANY OTHER ACTIVITY AND PARTICIPATION
PART 3: ENVIRONMENTAL FACTORS
•Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives.
Qualifier in environment: |
0 No barriers |
0 No facilitator |
Barriers or facilitator |
1 Mild barriers |
+1 Mild facilitator |
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2 Moderate barriers |
+2 Moderate facilitator |
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3 Severe barriers |
+3 Substantial facilitator |
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4 Complete barriers |
+4 Complete facilitator |
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Short List of Environment |
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Qualifier |
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barrier or facilitator |
e1. PRODUCTS AND TECHNOLOGY |
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e110 |
For personal consumption (food, medicines) |
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e115 |
For personal use in daily living |
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e120 |
For personal indoor and outdoor mobility and transportation |
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e125 Products for communication |
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e150 |
Design, construction and building products and technology of buildings for public use |
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e155 |
Design, construction and building products and technology of buildings for private use |
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e2. NATURAL ENVIRONMENT AND HUMAN MADE CHANGES TO |
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ENVIRONMENT |
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e225 |
Climate |
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e240 |
Light |
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e250 |
Sound |
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e3. SUPPORT AND RELATIONSHIPS |
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e310 |
Immediate family |
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e320 |
Friends |
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e325 |
Acquaintances, peers, colleagues, neighbours and community members |
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e330 People in position of authority |
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e340 Personal care providers and personal assistants |
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e355 |
Health professionals |
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e360 |
Health related professionals |
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e4. ATTITUDES |
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e410 |
Individual attitudes of immediate family members |
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e420 |
Individual attitudes of friends |
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e440 |
Individual attitudes of personal care providers and personal assistants |
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e450 |
Individual attitudes of health professionals |
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e455 |
Individual attitudes of health related professionals |
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e460 |
Societal attitudes |
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e465 |
Social norms, practices and ideologies |
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E5. SERVICES, SYSTEMS AND POLICIES |
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e525 |
Housing services, systems and policies |
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e535 |
Communication services, systems and policies |
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e540 |
Transportation services, systems and policies |
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e550 |
Legal services, systems and policies |
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e570 |
Social security, services, systems and policies |
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e575 |
General social support services, systems and policies |
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e580 |
Health services, systems and policies |
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e585 |
Education and training services, systems and policies |
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e590 |
Labour and employment services, systems and policies |
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ANY OTHER ENVIRONMENTAL FACTORS |
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ICF Checklist © World Health Organization, September 2003. |
Page 7 |
Part 4: OTHER CONTEXTUAL INFORMATION
4.1 Give a thumbnail sketch of the individual and any other relevant information.
4.2Include any Personal Factors as they impact on functioning (e.g. lifestyle, habits, social background, education, life events, race/ethnicity, sexual orientation and assets of the individual).
Appendix 1:
BRIEF HEALTH INFORMATION
[ ] Self Report |
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[ ] Clinician Administered |
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X.1 |
Height : __/__/__ cm (or |
inches) |
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X.2 |
Weight: __/__/__ kg |
(or |
pounds) |
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X.3 |
Dominant Hand (prior to health condition): Left [ ] |
Right [ ] |
Both hands equally [ ] |
X.4 |
How do you rate your physical health in the past month? |
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Very good [ ] |
Good [ ] |
Moderate [ ] |
Bad [ ] |
Very bad [ ] |
X.5 How do you rate your mental and emotional health in the past month?
Very good [ ] |
Good [ ] |
Moderate [ ] |
Bad [ ] |
Very bad [ ] |
X.6 Do you currently have any disease(s) or disorder(s) ?
[ |
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NO |
[ |
] YES |
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If |
YES, please specify:_________________________________ |
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_________________________________ |
X.7 Did you ever have any significant injuries that had an impact on your level of functioning? |
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NO |
[ |
] YES |
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If |
YES, please specify _________________________________ |
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X.8 Have you been hospitalized in the last year?
If YES, please specify reason(s) and for how long?
1._____________________________; ___. ___. ___ days
2._____________________________; ___. ___. ___ days
3._____________________________; ___. ___. ___ days
X.9 Are you taking any medication ( either prescribed or over the counter)?
If YES, please specify major medications
1._____________________________
2._____________________________
3._____________________________
ICF Checklist © World Health Organization, September 2003. |
Page 9 |
X.10 Do you smoke?
X.11 Do you consume alcohol or drugs?
If YES, please specify average daily quantity
Tobacco: |
__________________________ |
Alcohol: |
__________________________ |
Drugs: |
__________________________ |
X.12 Do you use any assistive device such as glasses, hearing aid, wheelchair, etc.?
If YES, please specify
_________________________________________
X.13 Do you have any person assisting you with your self care, shopping or other daily activities?
If YES, please specify person and assistance they provide
____________________________________________________
X.14 Are you receiving any kind of treatment for your health?
[ ] NO |
[ ] YES |
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If YES, please specify: |
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____________________________________________________ |
X.15 Additional significant information on your past and present health:
________________________________________________________________________
________________________________________________________________________
X.16 IN THE PAST MONTH, have you cut back (i.e. reduced) your usual activities or work because of your health condition? (a disease, injury, emotional reasons or alcohol or drug use)
[ ] NO |
[ ] YES |
If yes, how many days? _____ |
X.17 IN THE PAST MONTH, have you been totally unable to carry out your usual activities or work because of your health condition? (a disease, injury, emotional reasons or alcohol or drug use)
[ ] NO |
[ ] YES |
If yes, how many days? _____ |