Functioning

Date Taken:

1. Independent living No impairment Mild impairment Moderate impairment Moderate severe impairment Severe impairment Very severe impairment Extreme impairment

2. Work productivity No impairment Mild impairment Moderate impairment Moderate severe impairment Severe impairment Very severe impairment Extreme impairment

3. Immediate social network relationships No impairment Mild impairment Moderate impairment Moderate severe impairment Severe impairment Very severe impairment Extreme impairment

4. Extended social network relationships No impairment Mild impairment Moderate impairment Moderate severe impairment Severe impairment Very severe impairment Extreme impairment

History

Date Taken:	Score
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