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

1/20

b1140

Moderate impairment

Severe impairment

Complete impairment

Not specified

Not applicable

How much impairment does the person have in ...

Mild impairment

Physiological functions of body systems (including psychological functions)

No impairment

BODY FUNCTIONS

Orientation to time
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b1141

Orientation to place
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b117

Intellectual functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b126

Temperament and personality functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b130

Energy and drive functions (G)

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b1301

Motivation
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b134

Sleep functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b140

Attention functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b152

Emotional functions (G)

Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

2/20

Clinical examination

Technical investigation

b1528

Emotional functions, other specified

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b156

Perceptual functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b1561

Visual perception
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b1564

Tactile perception
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b1565

Visuospatial perception
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b163

Basic cognitive functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b164

Higher-level cognitive functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b167

Mental functions of language

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b210

Seeing functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b2152

Functions of external muscles of the eye

Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

3/20

Clinical examination

Technical investigation

b230

Hearing functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b260

Proprioceptive function
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b280

Sensation of pain (G)

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b320

Articulation functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b440

Respiration functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b445

Respiratory muscle functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b4501

Transportation of airways mucus

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b455

Exercise tolerance functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b510

Ingestion functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b525

Defecation functions
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

4/20

Clinical examination

Technical investigation

b530

Weight maintenance functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b620

Urination functions
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b710

Mobility of joint functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b715

Stability of joint functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b730

Muscle power functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b735

Muscle tone functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b740

Muscle endurance functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b755

Involuntary movement reaction functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b760

Control of voluntary movement functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b765

Involuntary movement functions

Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

5/20

Clinical examination

Technical investigation

b770

Gait pattern functions

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

b810

Protective functions of the skin

Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

6/20

Clinical examination

Technical investigation

s110

Structure of brain

Moderate impairment

Severe impairment

Complete impairment

Not specified

Not applicable

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

Mild impairment

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

No impairment

BODY STRUCTURES

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

s320

Structure of mouth

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

s730

Structure of upper extremity

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

s750

Structure of lower extremity

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

s760

Structure of trunk

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

7/20

Clinical examination

Technical investigation

s7700

Bones

Extent
0

Nature*
Location**
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

s7703

Extra-articular ligaments, fasciae, extramuscular

aponeuroses, retinacula, septa, bursae,
unspecified

Extent
0

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

8/20

ACTIVITIES AND PARTICIPATION

Severe difficulty

Complete difficulty

Not specified

Not applicable

C = capacity in ...

Moderate difficulty

P = performance of ...

Mild difficulty

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

No difficulty

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

P
d110

Watching
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d115

Listening
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d120

Other purposeful sensing

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d130

Copying
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d131

Learning through actions with objects

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d133

Acquiring language
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d137

Acquiring concepts
C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

9/20

Clinical examination

Technical investigation

P
d140

Learning to read
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d145

Learning to write
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d155

Acquiring skills
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d160

Focusing attention
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d166

Reading
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d170

Writing
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d172

Calculating
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d175

Solving problems
C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

10/20

Clinical examination

Technical investigation

P
d177

Making decisions
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d220

Undertaking multiple tasks

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d230

Carrying out daily routine (G)

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d250

Managing one's own behaviour

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d310

Communicating with - receiving - spoken messages

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d330

Speaking
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d331

Pre-talking
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d335

Producing nonverbal messages

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

11/20

Clinical examination

Technical investigation

P
d350

Conversation
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d360

Using communication devices and techniques

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d410

Changing basic body position

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d415

Maintaining a body position

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d420

Transferring oneself
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d430

Lifting and carrying objects

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d435

Moving objects with lower extremities

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d440

Fine hand use

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

12/20

Clinical examination

Technical investigation

P
d445

Hand and arm use

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d450

Walking (G)
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d455

Moving around (G)

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d460

Moving around in different locations

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d465

Moving around using equipment

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d470

Using transportation
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d510

Washing oneself
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d520

Caring for body parts

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

13/20

Clinical examination

Technical investigation

P
d530

Toileting
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d540

Dressing
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d550

Eating
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d560

Drinking
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d570

Looking after one's health

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d630

Preparing meals
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d640

Doing housework
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d710

Basic interpersonal interactions

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

14/20

Clinical examination

Technical investigation

P
d720

Complex interpersonal interactions

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d750

Informal social relationships

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d760

Family relationships
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d770

Intimate relationships
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d815

Preschool education
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d820

School education
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d845

Acquiring, keeping and terminating a job

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d850

Remunerative employment (G)

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

15/20

Clinical examination

Technical investigation

P
d860

Basic economic transactions

C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d880

Engagement in play
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d910

Community life
C
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the problem:

0

P
d920

Recreation and leisure

C
Sources of information:
Case history

Patient reported questionnaire

Description of the problem:

16/20

Clinical examination

Technical investigation

e110

Mild facilitator

No facilitator/barrier

Mild barrier

Moderate barrier

Substantial barrier

Complete barrier

Not specified

Not applicable

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

Moderate facilitator

How much of a facilitator or barrier does the person experience

with respect to ...

Severe facilitator

Make up the physical, social and attitudinal environment in which people

live and conduct their lives

Complete facilitator

ENVIRONMENTAL FACTORS

+4

+3

+2

+1

Products or substances for personal consumption

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e115

+3

+2

+1

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

e120

+3

+2

+1

Products and technology for personal indoor and outdoor

mobility and transportation
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e125

+3

+2

+1

Products and technology for communication

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e130

+3

+2

+1

Products and technology for education

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e140

+3

+2

+1

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

e150

+3

+2

+1

Design, construction and building products and technology

of buildings for public use
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e155

+3

+2

+1

Design, construction and building products and technology

of buildings for private use
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e160

+3

+2

+1

Products and technology of land development

Sources of information:
Case history

Patient reported questionnaire

Description of the facilitator/barrier:

17/20

Clinical examination

Technical investigation

+4

e165

+3

+2

+1

Assets
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e310

+3

+2

+1

Immediate family
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e315

+3

+2

+1

Extended family
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e320

+3

+2

+1

Friends
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e325

+3

+2

+1

Acquaintances, peers, colleagues, neighbours and

community members
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e330

+3

+2

+1

People in positions of authority

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e340

+3

+2

+1

Personal care providers and personal assistants

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e355

+3

+2

+1

Health professionals
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e410

+3

+2

+1

Individual attitudes of immediate family members

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e415

+3

+2

+1

Individual attitudes of extended family members

Sources of information:
Case history

Patient reported questionnaire

Description of the facilitator/barrier:

18/20

Clinical examination

Technical investigation

+4

e420

+3

+2

+1

Individual attitudes of friends

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e425

+3

+2

+1

Individual attitudes of acquaintances, peers, colleagues,

neighbours and community members
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e430

+3

+2

+1

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

e440

+3

+2

+1

Individual attitudes of personal care providers and personal

assistants
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e450

+3

+2

+1

Individual attitudes of health professionals

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e460

+3

+2

+1

Societal attitudes
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e465

+3

+2

+1

Social norms, practices and ideologies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e525

+3

+2

+1

Housing services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e540

+3

+2

+1

Transportation services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e550

+3

+2

+1

Legal services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Description of the facilitator/barrier:

19/20

Clinical examination

Technical investigation

+4

e555

+3

+2

+1

Associations and organizational services, systems and

policies
Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e560

+3

+2

+1

Media services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e570

+3

+2

+1

Social security services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e575

+3

+2

+1

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

e580

+3

+2

+1

Health services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Clinical examination

Technical investigation

Description of the facilitator/barrier:

+4

e585

+3

+2

+1

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

e590

+3

+2

+1

Labour and employment services, systems and policies

Sources of information:
Case history

Patient reported questionnaire

Description of the facilitator/barrier:

20/20

Clinical examination

Technical investigation