icf documentation form cp6 13years

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  • 7/23/2019 ICF Documentation Form CP6 13years

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    ICF Based Documentation Form

    Reminder: The categories of the Generic Set will automatically be included in the selection, if not already included. The

    categories of the Generic Set will be indicated by the letter (G).

    PATIENT INFORMATION

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    BODY FUNCTIONS

    Physiological functions of body systems (including psychological functions)

    How much impairment does the person have in ...

    N

    oimpairment

    M

    ildimpairment

    M

    oderateimpairment

    S

    evereimpairment

    C

    ompleteimpairment

    N

    otspecified

    N

    otapplicable

    0 1 2 3 4 8 9

    b1140 Orientation to time

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b1141 Orientation to place

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b117 Intellectual functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b126 Temperament and personality functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b130 Energy and drive functions (G)

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b1301 Motivation

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b134 Sleep functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b140 Attention functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b152 Emotional functions (G)

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    b1528 Emotional functions, other specified

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b156 Perceptual functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b1561 Visual perception

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b1564 Tactile perception

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b1565 Visuospatial perception

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b163 Basic cognitive functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b164 Higher-level cognitive functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b167 Mental functions of language

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b210 Seeing functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b2152 Functions of external muscles of the eye

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    b230 Hearing functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b260 Proprioceptive function

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b280 Sensation of pain (G)

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b320 Articulation functions

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b440 Respiration functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b445 Respiratory muscle functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b4501 Transportation of airways mucus

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b455 Exercise tolerance functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b510 Ingestion functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b525 Defecation functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    b530 Weight maintenance functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b620 Urination functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b710 Mobility of joint functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b715 Stability of joint functions

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b730 Muscle power functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b735 Muscle tone functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b740 Muscle endurance functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b755 Involuntary movement reaction functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b760 Control of voluntary movement functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b765 Involuntary movement functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    b770 Gait pattern functions

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    b810 Protective functions of the skin

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    BODY STRUCTURES

    Anatomical parts of the body such as organs, limbs and their components

    How much impairment does the person have in the ...Noimpairment

    Mildimpairment

    Moderateimpairment

    Severeimpairment

    Completeimpairment

    Notspecified

    Notapplicable

    0 1 2 3 4 8 9

    s110 Structure of brain Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    s320 Structure of mouth Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    s730 Structure of upper extremity Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    s750 Structure of lower extremity Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    s760 Structure of trunk Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    s7700 Bones Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    s7703Extra-articular ligaments, fasciae, extramuscularaponeuroses, retinacula, septa, bursae,unspecified

    Extent

    0 1 2 3 4 5 6 7 8 9

    Nature*

    Location**

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    * 0=no change in structure, 1=total absence, 2=partial absence, 3=additional part, 4=aberrant dimension, 5=discontinuity, 6= deviating position,7=qualitative changes in structure, 8=not specified, 9=not applicable

    ** 0=more than one region, 1=right, 2=left, 3=both sides, 4=front, 5=back, 6=proximal, 7=distal, 8=not specified, 9=not applicable

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    ACTIVITIES AND PARTICIPATION

    Execution of a task or action by an individual and involvement in a life situation

    How much difficulty does the person have in the ...

    P = performance of ...

    C = capacity in ... Nodifficulty

    M

    ilddifficulty

    M

    oderatedifficulty

    S

    everedifficulty

    C

    ompletedifficulty

    N

    otspecified

    N

    otapplicable

    0 1 2 3 4 8 9

    d110 WatchingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d115 ListeningP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d120 Other purposeful sensingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d130 CopyingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d131 Learning through actions with objectsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d133 Acquiring languageP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d137 Acquiring conceptsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    d140 Learning to readP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d145 Learning to writeP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d155 Acquiring skillsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d160 Focusing attentionP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d166 ReadingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d170 WritingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d172 CalculatingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d175 Solving problemsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    10/20

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    0 1 2 3 4 8 9

    d177 Making decisionsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d220 Undertaking multiple tasksP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d230 Carrying out daily routine (G)P

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d250 Managing one's own behaviourP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d310 Communicating with - receiving - spoken messagesP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d330 SpeakingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d331 Pre-talkingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d335 Producing nonverbal messagesP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    11/20

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    0 1 2 3 4 8 9

    d350 ConversationP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d360 Using communication devices and techniquesP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d410 Changing basic body positionP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d415 Maintaining a body positionP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d420 Transferring oneselfP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d430 Lifting and carrying objectsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d435 Moving objects with lower extremitiesP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d440 Fine hand useP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    d445 Hand and arm useP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d450 Walking (G)P

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d455 Moving around (G)P

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d460 Moving around in different locationsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d465 Moving around using equipmentP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d470 Using transportationP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d510 Washing oneselfP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d520 Caring for body partsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    d530 ToiletingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d540 DressingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d550 EatingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d560 DrinkingP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d570 Looking after one's healthP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d630 Preparing mealsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d640 Doing houseworkP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d710 Basic interpersonal interactionsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

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    0 1 2 3 4 8 9

    d720 Complex interpersonal interactionsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d750 Informal social relationshipsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d760 Family relationshipsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d770 Intimate relationshipsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d815 Preschool educationP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d820 School educationP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d845 Acquiring, keeping and terminating a jobP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d850 Remunerative employment (G)P

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    15/20

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    0 1 2 3 4 8 9

    d860 Basic economic transactionsP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d880 Engagement in playP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    0 1 2 3 4 8 9

    d910 Community lifeP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigationDescription of the problem:

    0 1 2 3 4 8 9

    d920 Recreation and leisureP

    C

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the problem:

    16/20

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    ENVIRONMENTAL FACTORS

    Make up the physical, social and attitudinal environment in which peoplelive and conduct their lives

    How much of a facilitator or barrier does the person experiencewith respect to ...

    You can also rate environmental factors as both a facilitator and barrier

    if applicable. Completefacilitator

    S

    everefacilitator

    M

    oderatefacilitator

    M

    ildfacilitator

    N

    ofacilitator/barrier

    M

    ildbarrier

    M

    oderatebarrier

    S

    ubstantialbarrier

    C

    ompletebarrier

    N

    otspecified

    N

    otapplicable

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e110 Products or substances for personal consumption

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e115 Products and technology for personal use in daily living

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e120Products and technology for personal indoor and outdoormobility and transportationSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e125 Products and technology for communication

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e130 Products and technology for education

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e140 Products and technology for culture, recreation and sport

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e150Design, construction and building products and technologyof buildings for public useSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e155Design, construction and building products and technologyof buildings for private useSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e160 Products and technology of land development

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    17/20

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    +4 +3 +2 +1 0 1 2 3 4 8 9

    e165 Assets

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e310 Immediate family

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e315 Extended family

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e320 Friends

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e325Acquaintances, peers, colleagues, neighbours andcommunity membersSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e330 People in positions of authority

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e340 Personal care providers and personal assistants

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e355 Health professionals

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e410 Individual attitudes of immediate family members

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e415 Individual attitudes of extended family members

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

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    +4 +3 +2 +1 0 1 2 3 4 8 9

    e420 Individual attitudes of friends

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e425Individual attitudes of acquaintances, peers, colleagues,neighbours and community membersSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e430 Individual attitudes of people in positions of authority

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e440Individual attitudes of personal care providers and personalassistants

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e450 Individual attitudes of health professionals

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e460 Societal attitudes

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e465 Social norms, practices and ideologies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e525 Housing services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e540 Transportation services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e550 Legal services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    19/20

  • 7/23/2019 ICF Documentation Form CP6 13years

    20/20

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e555Associations and organizational services, systems andpoliciesSources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e560 Media services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e570 Social security services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e575 General social support services, systems and policies

    Sources of information:Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e580 Health services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e585 Education and training services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier:

    +4 +3 +2 +1 0 1 2 3 4 8 9

    e590 Labour and employment services, systems and policies

    Sources of information:

    Case history Patient reported questionnaire Clinical examination Technical investigation

    Description of the facilitator/barrier: