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

Complete impairment
Moderate impairment

Severe impairment
Mild impairment
Physiological functions of body systems (including psychological functions)

No impairment

Not applicable
Not specified
How much impairment does the person have in ...

0 1 2 3 4 8 9

b110 Consciousness functions

General mental functions of the state of awareness and alertness, including the clarity and continuity of the wakeful state.
Inclusions: functions of the state, continuity and quality of consciousness; loss of consciousness, coma, vegetative states, fugues,
trance states, possession states, drug-induced altered consciousness, delirium, stupor
Exclusions: orientation functions (b114); energy and drive functions (b130); sleep functions (b134)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1100 State of consciousness

Mental functions that when altered produce states such as clouding of consciousness, stupor or coma.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1101 Continuity of consciousness

Mental functions that produce sustained wakefulness, alertness and awareness and, when disrupted, may produce fugue,
trance or other similar states.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1102 Quality of consciousness

Mental functions that when altered effect changes in the character of wakeful, alert and aware sentience, such as
drug-induced altered states or delirium.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1108 Consciousness 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

b1109 Consciousness functions, unspecified

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

b1140 Orientation to time

Mental functions that produce awareness of day, date, month and year.

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

General mental functions, required to understand and constructively integrate the various mental functions, including all
cognitive functions and their development over the life span.
Inclusions: functions of intellectual growth; intellectual retardation, mental retardation, dementia
Exclusions: memory functions (b144); thought functions (b160); higher-level cognitive functions (b164)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b122 Global psychosocial functions

General mental functions, as they develop over the life span, required to understand and constructively integrate the mental
functions that lead to the formation of the interpersonal skills needed to establish reciprocal social interactions, in terms of
both meaning and purpose.
Inclusions: such as in autism
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1263 Psychic stability

Mental functions that produce a personal disposition that is even-tempered, calm and composed, as contrasted to being
irritable, worried, erratic and moody.

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)

General mental functions of physiological and psychological mechanisms that cause the individual to move towards
satisfying specific needs and general goals in a persistent manner.
Inclusions: functions of energy level, motivation, appetite, craving (including craving for substances that can be abused) and impulse
control
Exclusions: consciousness functions (b110); temperament and personality functions (b126); sleep functions (b134); psychomotor
functions (b147); emotional functions (b152)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1300 Energy level

Mental functions that produce vigour and stamina.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1304 Impulse control

Mental functions that regulate and resist sudden intense urges to do something.

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

b134 Sleep functions

General mental functions of periodic, reversible and selective physical and mental disengagement from one's immediate
environment accompanied by characteristic physiological changes.
Inclusions: functions of amount of sleeping, and onset, maintenance and quality of sleep; functions involving the sleep cycle, such as
in insomnia, hypersomnia and narcolepsy
Exclusions: consciousness functions (b110); energy and drive functions (b130); attention functions (b140); psychomotor functions
(b147)
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

Specific mental functions of focusing on an external stimulus or internal experience for the required period of time.
Inclusions: functions of sustaining attention, shifting attention, dividing attention, sharing attention; concentration; distractibility
Exclusions: consciousness functions (b110); energy and drive functions (b130); sleep functions (b134); memory functions (b144);
psychomotor functions (b147); perceptual functions (b156)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1440 Short-term memory

Mental functions that produce a temporary, disruptable memory store of around 30 seconds duration from which information
is lost if not consolidated into long-term memory.

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)

Specific mental functions related to the feeling and affective components of the processes of the mind.
Inclusions: functions of appropriateness of emotion, regulation and range of emotion; affect; sadness, happiness, love, fear, anger,
hate, tension, anxiety, joy, sorrow; lability of emotion; flattening of affect
Exclusions: temperament and personality functions (b126); energy and drive functions (b130)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1521 Regulation of emotion

Mental functions that control the experience and display of affect.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1522 Range of emotion

Mental functions that produce the spectrum of experience of arousal of affect or feelings such as love, hate, anxiousness,
sorrow, joy, fear and anger.

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

b156 Perceptual functions

Specific mental functions of recognizing and interpreting sensory stimuli.
Inclusions: functions of auditory, visual, olfactory, gustatory, tactile and visuospatial perception, such as a hallucination or illusion
Exclusions: consciousness functions (b110); orientation functions (b114); attention functions (b140); memory functions (b144); mental
functions of language (b167); seeing and related functions (b210-b229); hearing and vestibular functions (b230-b249); additional
sensory functions (b250-b279)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1560 Auditory perception

Mental functions involved in discriminating sounds, tones, pitches and other acoustic stimuli.

Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b160 Thought functions

Specific mental functions related to the ideational component of the mind.
Inclusions: functions of pace, form, control and content of thought; goal-directed thought functions, non-goal directed thought
functions; logical thought functions, such as pressure of thought, flight of ideas, thought block, incoherence of thought, tangentiality,
circumstantiality, delusions, obsessions and compulsions
Exclusions: intellectual functions (b117); memory functions (b144); psychomotor functions (b147); perceptual functions (b156);
higher-level cognitive functions (b164); mental functions of language (b167); calculation functions (b172)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1602 Content of thought

Mental functions consisting of the ideas that are present in the thinking process and what is being conceptualized.
Inclusions: impairments of delusions, overvalued ideas and somatization
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

b1603 Control of thought

Mental functions that provide volitional control of thinking and are recognized as such by the person.
Inclusions: impairments of rumination, obsession, thought broadcast and thought insertion
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

Specific mental functions especially dependent on the frontal lobes of the brain, including complex goal-directed behaviours
such as decision-making, abstract thinking, planning and carrying out plans, mental flexibility, and deciding which
behaviours are appropriate under what circumstances; often called executive functions.
Inclusions: functions of abstraction and organization of ideas; time management, insight and judgement; concept formation,
categorization and cognitive flexibility
Exclusions: memory functions (b144); thought functions (b160); mental functions of language (b167); calculation functions (b172)
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

b180 Experience of self and time functions

Specific mental functions related to the awareness of one's identity, one's body, one's position in the reality of one's
environment and of time.
Inclusions: functions of experience of self, body image and time
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)

Sensation of unpleasant feeling indicating potential or actual damage to some body structure.
Inclusions: sensations of generalized or localized pain in one or more body part, pain in a dermatome, stabbing pain, burning pain, dull
pain, aching pain; impairments such as myalgia, analgesia and hyperalgesia
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:

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

Complete difficulty
Moderate difficulty

Severe difficulty

Not applicable
How much difficulty does the person have in the ...

Mild difficulty

Not specified
No difficulty
P = performance of ...
C = capacity in ...
0 1 2 3 4 8 9

P
d155 Acquiring skills
C
Developing basic and complex competencies in integrated sets of actions or tasks so as to initiate and follow through with
the acquisition of a skill, such as manipulating tools or playing games like chess.
Inclusion: acquiring basic and complex skills
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d175 Solving problems
C
Finding solutions to questions or situations by identifying and analysing issues, developing options and solutions,
evaluating potential effects of solutions, and executing a chosen solution, such as in resolving a dispute between two
people.
Inclusions: solving simple and complex problems
Exclusions: thinking (d163); making decisions (d177)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d230 Carrying out daily routine (G)
C
Carrying out simple or complex and coordinated actions in order to plan, manage and complete the requirements of
day-to-day procedures or duties, such as budgeting time and making plans for separate activities throughout the day.
Inclusions: managing and completing the daily routine; managing one's own activity level
Exclusion: undertaking multiple tasks (d220)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d240 Handling stress and other psychological demands
C
Carrying out simple or complex and coordinated actions to manage and control the psychological demands required to carry
out tasks demanding significant responsibilities and involving stress, distraction or crises, such as driving a vehicle during
heavy traffic or taking care of many children.
Inclusions: handling responsibilities; handling stress and crisis
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

P
d450 Walking (G)
C
Moving along a surface on foot, step by step, so that one foot is always on the ground, such as when strolling, sauntering,
walking forwards, backwards or sideways.
Inclusions: walking short or long distances; walking on different surfaces; walking around obstacles
Exclusions: transferring oneself (d420); moving around (d455)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d455 Moving around (G)
C
Moving the whole body from one place to another by means other than walking, such as climbing over a rock or running
down a street, skipping, scampering, jumping, somersaulting or running around obstacles.
Inclusions: crawling, climbing, running, jogging, jumping and swimming
Exclusions: transferring oneself (d420); walking (d450)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d570 Looking after one's health
C
Ensuring physical comfort, health and physical and mental well-being, such as by maintaining a balanced diet, and an
appropriate level of physical activity, keeping warm or cool, avoiding harms to health, following safe sex practices, including
using condoms, getting immunizations and regular physical examinations.
Inclusions: ensuring one's physical comfort; managing diet and fitness; maintaining one's health
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d710 Basic interpersonal interactions
C
Interacting with people in a contextually and socially appropriate manner, such as by showing consideration and esteem
when appropriate, or responding to the feelings of others.
Inclusions: showing respect, warmth, appreciation, and tolerance in relationships; responding to criticism and social cues in
relationships; and using appropriate physical contact in relationships
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d720 Complex interpersonal interactions
C
Maintaining and managing interactions with other people, in a contextually and socially appropriate manner, such as by
regulating emotions and impulses, controlling verbal and physical aggression, acting independently in social interactions
and acting in accordance with social rules and conventions.
Inclusions: forming and terminating relationships; regulating behaviours within interactions; interacting according to social rules; and
maintaining social space
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

P
d760 Family relationships
C
Creating and maintaining kinship relationships, such as with members of the nuclear family, extended family, foster and
adopted family and step-relationships, more distant relationships such as second cousins or legal guardians.
Inclusions: parent-child and child-parent relationships, sibling and extended family relationships
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d845 Acquiring, keeping and terminating a job
C
Seeking, finding and choosing employment, being hired and accepting employment, maintaining and advancing through a
job, trade, occupation or profession, and leaving a job in an appropriate manner.
Inclusions: seeking employment; preparing a resume or curriculum vitae; contacting employers and preparing interviews; maintaining
a job; monitoring one's own work performance; giving notice; and terminating a job
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:
0 1 2 3 4 8 9

P
d910 Community life
C
Engaging in all aspects of community social life, such as engaging in charitable organizations, service clubs or professional
social organizations.
Inclusions: informal and formal associations; ceremonies
Exclusions: non-remunerative employment (d855); recreation and leisure (d920); religion and spirituality (d930); political life and
citizenship (d950)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the problem:

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

No facilitator/barrier
live and conduct their lives.

Complete facilitator

Moderate facilitator

Substantial barrier
Severe facilitator

Complete barrier
Moderate barrier

Not applicable
Mild facilitator

Not specified
How much of a facilitator or barrier does the person experience

Mild barrier
with respect to ...
You can also rate environmental factors as both a facilitator and barrier
if applicable.
+4 +3 +2 +1 0 1 2 3 4 8 9

e310 Immediate family

Individuals related by birth, marriage or other relationship recognized by the culture as immediate family, such as spouses,
partners, parents, siblings, children, foster parents, adoptive parents and grandparents.
Exclusions: extended family (e315); personal care providers and personal assistants (e340)
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

All service providers working within the context of the health system, such as doctors, nurses, physiotherapists,
occupational therapists, speech therapists, audiologists, orthotist-prosthetists, medical social workers.
Exclusion: other professionals (e360)
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

General or specific opinions and beliefs of immediate family members about the person or about other matters (e.g. social,
political and economic issues) that influence individual behaviour and actions.
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

General or specific opinions and beliefs of health professionals about the person or about other matters (e.g. social, political
and economic issues) that influence individual behaviour and actions.
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

General or specific opinions and beliefs generally held by people of a culture, society, subcultural or other social group
about other individuals or about other social, political and economic issues that influence group or individual behaviour and
actions.
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

Services, systems and policies aimed at providing income support to people who, because of age, poverty, unemployment,
health condition or disability require public assistance that is funded either by general tax revenues or contributory
schemes.
Exclusion: economic services, systems and policies (e565)
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

e580 Health services, systems and policies

Services, systems and policies for preventing and treating health problems, providing medical rehabilitation and promoting a
healthy lifestyle.
Exclusion: general social support services, systems and policies (e575)
Sources of information:
Case history Patient reported questionnaire Clinical examination Technical investigation
Description of the facilitator/barrier:

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