47 PCN Functional Activities Questionnaire

Score each question on a 4 point scale:

  • 0 = normal,
  • 1 = does with difficulty,
  • 2 = requires assistance,
  • 3 = dependent

In the past 4 weeks, did the patient have any difficulty or need help with:?

  1. writing checks, paying bills, keeping financial records
  2. assembling tax records, business affairs, papers
  3. shopping alone – clothes, household, groceries
  4. playing a game of skill or working on a hobby
  5. heating water, making coffee, turning off stove
  6. preparing a balanced meal
  7. keeping track of current events
  8. paying attention to, understanding, or discussing a TV program/book/magazine
  9. remembering appointment, family occasion, holiday, medication
  10. traveling out of the neighborhood, driving, arranging to take bus

Scoring:

  • normal = 0-1
  • mild cognitive impairment = 4-9
  • mild dementia = 10-13

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Reference Notes for Palliative Care Consultation Copyright © 2018 by Robert F. Johnson MD, MEd is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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