1. May I, Can I, Should I? Yes or No 2. Overall Average Average Condition? -10 to +10 3. Worst Condition? Anything less than +10 4. Specified Areas of particular interest? -10 to +10 5. Progress toward Specified Goals? 0 to %100
This side is for Lower Function, Sustaining and Rebuilding Condition(s) Non-Beneficial Negative Effects
This side is for Better B etter Functioning Sustaining and Rebuilding Condition(s) Beneficial Positive Effects
Reference Person
10
Ready for Question.
20
YES
?
30 40
3
2
4 5
Mild
6 7
Severe
1
1 Bal. k
50 2
3 60
4 5
Mild +
6 Strong +
NO
10
7
80 8
8 9
70
Less than Detrimental Critical
Better Beneficial Very Strong
9 10
90 100
This side is for Better B etter Functioning
This side is for Lower Function, Sustaining Rebuilding and Condition(s) Non-Beneficial Negative Effects
Sustaining and Rebuilding Condition(s) Beneficial Positive Effects
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