Demographic information ICF CORE SETS FOR STROKE H 1 checklist [1] [2] [3] [4] H2 Date / / H3 Case ID,, H4 Participant No,, day month year CE or CS Case No 1st or 2nd Evalu FTC Site Participant A DEMOGRAPHIC INFORMATION A 1 : : A 2 : : A 3 A 4 ( ) A 5 ( ) A 6 [1] [4] [2] [5] [3] [6] A 7 [1] [6] [2] [7] ( ) [3] [8] ( ) [4] [9] [5] A 8, [1] [2] ICD code : [3] ICD code : [4] ICD code : [5],, [ ] ICF Checklist 1 : ICF CORE SETS FOR STROKE 2 :,,,,,,,,,,, 3 : Szilvia Geyh et al ICF CORE SETS FOR STROKE J Rehabil Med 2004; Suppl 44: 135 141
Body functions PART 1a: IMPAIRMENTS OF BODY FUNCTIONS : 0 1 2 Extent of impairments 3 4 8 9 Short List of Body Functions b1 MENTAL FUNCTIONS b110 Consciousness functions b1100 State of Consciousness b1101 Continuity of Consciousness b1102 Quality of Consciousness b114 Orientation functions b1140 Orientation to time b1141 Orientation to place b1142 Orientation to person b11420 b11421 Orientation to self Orientation to others b117 Intellectual functions b126 Temperament and personality functions b1260 Extraversion b1261 Agreeableness b1262 Conscientiousness b1263 Psychic stability b1264 Openness to experience b1265 Optimism b1266 Confidence b1267 Trustworthiness b130 Energy and drive functions b1300 Energy level b1301 Motivation b1302 Appetite b1303 Craving b1304 Impulse control b134 Sleep functions b1340 Amount of sleep b1341 Onset of sleep b1342 Maintenance of sleep b1343 Quality of sleep b1344 Functions involving the sleep cycle b140 Attention functions
Body functions Short List of Body Functions b1400 Sustaining attention b1401 Shifting attention b1402 Dividing attention b1403 Sharing attention b144 Memory functions b1440 Short-term memory b1441 Long -term memory b1442 Retrieval of memory b152 Emotional functions b1520 Appropriateness of emotion b1521 Regulation of emotion b1522 Range of emotion b156 Perceptual functions b1560 Auditory perception b1561 Visual perception b1562 Olfactory perception b1563 Gustatory perception b1564 Tactile perception b1565 Visuospatial perception b164 Higher-level cognitive functions b1640 Abstraction b1641 Organization and planning b1642 Time management b1643 Cognitive flexibility b1644 Insight b1645 Judgement b1646 Problem-solving b167 Mental functions of language b1670 Reception of language b16700 b16701 Reception of spoken language Reception of written language b16702 Reception of sign language b1671 Expression of language b16710 b16711 Expression of spoken language Expression of written language b16712 Expression of sign language b1672 Integrative language functions b172 Calculation functions b1720 Simple calculation b1721 Complex calculation
Body functions Short List of Body Functions b176 Mental function of sequencing complex movements b180 Experience of self and time functions b1800 Experience of self b1801 Body image b1802 Experience of time b2 SENSORY FUNCTIONS AND PAIN b210 Seeing functions b2100 Visual acuity functions b21000 b21001 b21002 b21003 Binocular acuity of distant vision Monocular acuity of distant vision Binocular acuity of near vision Monocular acuity of near vision b2101 Visual field functions b2102 Quality of vision b21020 Light sensitivity b21021 Colour vision b21022 Contrast sensitivity b21023 ( ) Visual picture quality b215 Functions of structures adjoining the eye b2150 ( ) Functions of internal muscles of the eye b2151 Functions of the eyelid b2152 ( ; ) Functions of external muscles of the eye b2153 Functions of lachrymal glands b260 Proprioceptive function b265 Touch function b270 Sensory functions related to temperature and other stimuli b2700 Sensitivity to temperature b2701 Sensitivity to vibration b2702 Sensitivity to pressure b2703 Sensitivity to a noxious stimulus b280 Sensation of pain b2800 Generalized pain b2801 Pain in body part b28010 Pain in head and neck b28011 Pain in chest b28012 Pain in stomach or abdomen b28013 b28014 b28015 b28016 Pain in back Pain in upper limb Pain in lower limb Pain in joints
Body functions Short List of Body Functions b2802 Pain in multiple body parts b2803 Radiating pain in a dermatome b2804 Radiating pain in a segment or region b3 VOICE AND SPEECH FUNCTIONS b310 Voice functions b3100 Production of voice b3101 Quality of voice b320 Articulation functions b330 Fluency and rhythm of speech functions b3300 Fluency of speech b3301 Rhythm of speech b3302 Speed of speech b3303 Melody of speech b4,, FUNCTIONS OF THE CARDIOVASCULAR, HAEMATOLOGICAL, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS b410 Heart functions b4100 Heart rate b4101 Heart rhythm b4102 Contraction force of ventricular muscles b4103 Blood supply to the heart b415 Blood vessel functions b4150 Functions of arteries b4151 Functions of capillaries b4152 Functions of veins b420 Blood pressure functions b4200 Increased blood pressure b4201 Decreased blood pressure b4202 Maintenance of blood pressure b455 Exercise tolerance functions b4550 General physical endurance b4551 Aerobic capacity b4552 Fatiguability b5, FUNCTIONS OF THE DIGESTIVE, METABOLIC AND ENDOCRINE SYSTEM b510 Ingestion functions b5100 Sucking b5101 Biting b5102 Chewing b5103 Manipulation of food in the mouth b5104 Salivation b5105 Swallowing b51050 Oral swallowing
Body functions Short List of Body Functions b51051 b51052 Pharyngeal swallowing Oesophageal swallowing b5106 Regurgitation and vomiting b525 Defecation functions b5250 Elimination of faeces b5251 Faecal consistency b5252 Frequency of defecation b5253 Faecal continence b5254 Flatulence b535 Sensations associated with the digestive system b5350 Sensation of nausea b5351 Feeling bloated b5352 Sensation of abdominal cramp b6 GENITOURINARY AND REPRODUCTIVE FUNCTIONS b620 Urination functions b6200 Urination b6201 Frequency of urination b6202 Urinary continence b640 Sexual functions b6400 Functions of sexual arousal phase b6401 Functions of sexual preparatory phase b6402 Functions of orgasmic phase b6403 Functions of sexual resolution phase b7 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS b710 Mobility of joint functions b7100 Mobility of a single joint b7101 Mobility of several joints b7102 Mobility of joints generalized b715 Stability of joint functions b7150 Stability of a single joint b7151 Stability of several joints b7152 Stability of joints generalized b730 Muscle power functions b7300 Power of isolated muscles and muscle groups b7301 Power of muscles of one limb b7302 Power of muscles of one side of the body b7303 Power of muscles in lower half of the body b7304 Power of muscles of all limbs b7305 Power of muscles of the trunk b7306 Power of all muscles of the body b735 Muscle tone functions
Body functions Short List of Body Functions b7350 Tone of isolated muscles and muscle groups b7351 Tone of muscles of one limb b7352 Tone of muscles of one side of body b7353 Tone of muscles of lower half of body b7354 Tone of muscles of all limbs b7355 Tone of muscles of trunk b7356 Tone of muscles of the body b740 Muscle endurance functions b7400 Endurance of isolated muscles b7401 Endurance of muscle groups b7402 Endurance of all muscles of the body b750 Motor reflex functions b7500 Stretch motor reflex b7501 Reflexes generated by noxious stimuli b7502 Reflexes generated by other exteroceptive stimuli b755 Involuntary movement reaction functions b760 Control of voluntary movements functions b7600 Control of simple voluntary movements b7601 Control of complex voluntary movements b7602 Coordination of voluntary movements b7603 Supportive functions of arm or leg b770 Gait pattern functions
Body structures PART 1b: IMPAIRMENTS OF BODY STRUCTURES : Extent of impairment 0 No impairment 1 Mild impairment 2 Moderate impairment 3 Severe impairment 4 Complete impairment 8 Not specified 9 Not applicable : Nature of the change 0 No change in structure 1 Total absence 2 Partial absence 3 Additional part 4 Aberrant dimensions 5 Discontinuity 6 Deviating position 7 Qualitative changes in structure, including accumulation of fluid 8 Not specified 9 Not applicable : Location 0 More than one region 1 right 2 left 3 both sides 4 front 5 back 6 proximal 7 distal Short List of Body Structures s1 STRUCTURES OF THE NERVOUS SYSTEM s110 Structure of brain s1100 Structure of cortical lobes s11000 Frontal lobe s11001 Temporal lobe s11002 Parietal lobe s11003 Occipital lobe s1101 Structure of midbrain s1102 Structure of diencephalon s1103 Basal ganglia and related structures s1104 Structure of cerebellum s1105 Structure of brain stem s11050 Medulla oblongata s11051 Pons s1106 Structure of cranial nerves 1 Extent 2 Nature 3 Locations s4, STRUCTURES OF THE CARDIOVASCULAR, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS s410 Structure of cardiovascular system s4100 Heart s41000 Atria s41001 Ventricles
Body structures Short List of Body Structures s4101 Arteries s4102 Veins s4103 Capillaries 1 Extent 2 Nature 3 Locations s7 STRUCTURES RELATED TO MOVEMENT s720 Structure of shoulder region s7200 Bones of shoulder region s7201 Joints of shoulder region s7202 Muscles of shoulder region s7203 Ligaments and fasciae of shoulder region s730 Structure of upper extremity s7300 Structure of upper arm s73000 Bones of upper arm s73001 Elbow joint s73002 Muscles of upper arm s73003 Ligaments and fasciae of upper arm s7301 Structure of forearm s73010 Bones of forearm s73011 Wrist joint s73012 Muscles of forearm s73013 Ligaments and fasciae of forearm s7302 Structure of hand s73020 Bones of hand s73021 Joints of hand and fingers s73022 Muscles of hand s73023 Ligaments and fasciae of hand s750 Structure of lower extremity s7500 Structure of thigh s75000 Bones of thigh s75001 Hip joint s75002 Muscles of thigh s75003 Ligaments and fasciae of thigh s7501 Structure of lower leg s75010 Bones of lower leg s75011 Knee joint s75012 Muscles of lower leg s75013 Ligaments and fasciae of lower leg s7502 Structure of ankle and foot s75020 Bones of ankle and foot s75021, Ankle joint and joints of foot and toes
Body structures Short List of Body Structures s75022 Muscles of ankle and foot 1 2 3 Extent Nature Locations s75023 Ligaments and fasciae of ankle and foot
Activities & Participation PART 2: ACTIVITIES LIMITATION & PARTICIPATION RESTRICTION : (Performance) (Participation Restriction) 0 (No difficulty) 1 (Mild difficulty) 2 (Moderate difficulty) 3 (Severe difficulty) 4 (Complete difficulty) 8 (Not specified) 9 (Not applicable) : (Capacity; ) (Activity Limitation) 0 (No difficulty) 1 (Mild difficulty) 2 (Moderate difficulty) 3 (Severe difficulty) 4 (Complete difficulty) 8 (Not specified) 9 (Not applicable) Short List of A&P domains d1 LEARNING AND APPLYING KNOWLEDGE d115 Listening d155 Acquiring skills d1550 Acquiring basic skills d1551 Acquiring complex skills d160 Focusing attention d166 Reading d170 Writing d172 Calculating d175 Solving problems d1750 Solving simple problems d1751 Solving complex problems d2 GENERAL TASKS AND DEMANDS d210 Undertaking a single task d2100 Undertaking a simple task d2101 Undertaking a complex task d2102 Undertaking a single task independently d2103 Undertaking a single task in a group d220 Undertaking multiple tasks d2200 Carrying out multiple tasks d2201 Completing multiple tasks d2202 Undertaking multiple tasks independently d2203 Undertaking multiple tasks in a group d230 Carrying out dairy routine d2301 Managing daily routine d2302 Completing the dairy routine Performance Capacity
Activities & Participation Short List of A&P domains d2303 Managing one s own activity level d240 Handling stress and other psychological demands d2400 Handling responsibilities d2401 Handling stress d2402 Handling crisis d3 COMMUNICATION d310 Communicating with-receivingspoken messages d315 Communicating with-receivingnonverbal messages d3150 Communicating withreceiving-body gestures d3151 Communicating with-receiving-general signs and symbols d3152 Communicating withreceiving-drawing and photographs d325 Communicating with-receivingwritten messages d330 Speaking d335 Producing nonverbal messages d3350 Producing body language d3351 Producing signs and symbols d3352 Producing drawings and photographs d345 Writing messages d350 Conversation d3500 Starting a conversation d3501 Sustaining a conversation d3502 Ending a conversation d3503 Conversing with one person d3504 Conversing with many people d360 Using communication devices and techniques d4 MOBILITY d3600 Using telecommunication devices d3601 Using writing machines d3602 Using communication techniques d410 Changing basic body position d4100 Lying down d4101 Squatting d4102 Kneeling d4103 Sitting d4104 Standing d4105 Bending Performance Capacity
Activities & Participation Short List of A&P domains d4106 Shifting the body s centre of gravity d415 Maintaining a body position d4150 Maintaining a lying position d4151 Maintaining a squatting position d4152 Maintaining a kneeling position d4153 Maintaining a sitting position d4154 Maintaining a standing position d420 Transferring oneself d4200 Transferring oneself while sitting d4201 Transferring oneself while lying d430 Lifting and carrying objects d4300 Lifting d4301 Carrying in the hands d4302 Carrying in the arms d4303,, Carrying on shoulders, hip and back d4304 Carrying on the head d4305 Putting down objects d440 Fine hand use d4400 Picking up d4401 Grasping d4402 Manipulating d4403 Releasing d445 Hand and arm use d4450 Pulling d4451 Pushing d4452 Reaching d4453 Turning or twisting the hands or arms d4454 Throwing d4455 Catching d450 Walking d4500 Walking short distances d4501 Walking long distances d4502 Walking on different surfaces d4503 Walking around obstacles d455 Moving around d4550 Crawling d4551 Climbing d4552 Running d4553 Jumping Performance Capacity
Activities & Participation d4554 Swimming Short List of A&P domains d460 Moving around in different locations d4600 Moving around within the home d4601 Moving around within buildings other than home d4602 Moving around outside the home and other buildings d465 Moving around using equipment d470 Using transportation d4700 Using human-powered vehicles d4701 Using private motorized transportation d4702 Using public motorized transportation d475 Driving d4750 Driving human-powered transportation d4751 Driving motorized vehicles d4752 Driving animal-powered vehicles d5 SELF-CARE d510 Washing oneself d5100 Washing body parts d5101 Washing whole body d5102 Drying oneself d520 Caring for body parts d5200 Caring for skin d5201 Caring for teeth d5202 Caring for hair d5203 Caring for fingernails d5204 Caring for toenails d530 Toileting d5300 Regulating urination d5301 Regulating defecation d5302 Menstrual care d540 Dressing d5400 Putting on clothes d5401 Taking off clothes d5402 Putting on footwear d5403 Taking off footwear d5404 Choosing appropriate clothing d550 Eating d570 Looking after one s health d5700 Ensuring one s physical comfort d5701 M a n a g i n g d i e t a n d f i t n e s s Performance Capacity
Activities & Participation Short List of A&P domains d5702 Maintaining one s health Performance Capacity d6 DOMESTIC LIFE d620 Acquisition of goods and services d6200 Shopping d6201 Gathering daily necessities d630 Preparing meals d6300 Preparing simple meals d6301 Preparing complex meals d640 Doing housework d6400 Washing and drying clothes and garments d6401 Cleaning cooking area and utensils d6402 Cleaning living area d6403 Using household appliances d6404 Storing daily necessities d6405 Disposing of garbage d7 INTERPERSONAL INTERACTIONS AND RELATIONSHIPS d710 Basic interpersonal interactions d7100 Respect and warmth in relationships d7101 Appreciation in relationships d7102 Tolerance in relationships d7103 Criticism in relationships d7104 Social cues in relationships d7105 Physical contact in relationships d750 Informal social relationships d7500 Informal relationships with friends d7501 Informal relationships with neighbours d7502 Informal relationships with acquaintances d7503 Informal relationships with coinhabitants d7504 Informal relationships with peers d760 Family relationships d7600 Parent-child relationships d7601 Child-parent relationships d7602 Sibling relationships d770 Intimate relationships d7700 Romantic relationships d7701 Spousal relationships d7702 Sexual relationships d8 MAJOR LIFE AREAS d845,, Acquiring, keeping and terminating a job
Activities & Participation Short List of A&P domains d8450 Seeking employment d8451 Maintaining a job d8452 Terminating a job d850 Remunerative employment d8500 Self-employment d8501 Part-time employment d8502 Full-time employment d855 Non-remunerative employment d860 Basic economic transactions d870 Economic self-sufficiency d8700 Personal economic resources d8701 Public economic entitlements Performance Capacity d9, COMMUNITY, SOCIAL AND CIVIC LIFE d910 Community life d9100 Informal associations d9101 Formal associations d9102 Ceremonies d920 Recreation and leisure d9200 Play d9201 Sports d9202 Arts and culture d9203 Crafts d9204 Hobbies d9205 Socializing ANY OTHER ACTIVITY AND PARTICIPATION
Environmental factors PART 3: ENVIRONMENTAL FACTORS in environment: Barriers or facilitator 0 No barriers ( ) 1 Mild barriers ( ) 2 Moderate barriers ( ) 3 Severe barriers ( ) 4 Complete barriers ( ) 0 No facilitator ( ) +1 Mild facilitator ( ) +2 Moderate facilitator ( ) +3 Substantial facilitator ( ) +4 Complete facilitator ( ) Short List of ENVIRONMENT e1 PRODUCTS AND TECHNOLOGY e110 Products or substances for personal consumption e1100 Food e1101 Drugs e115 Products and technology for personal use in daily living e1150 General products and technology for personal use in daily living e1151 Assistive products and technology for personal use in daily living e120 Products and technology for personal indoor and outdoor mobility and transportation e1200 General products and technology for personal indoor and outdoor mobility and transportation e1201 Assistive products and technology for personal indoor and outdoor mobility and transportation e125 Products and technology for communication e1250 General products and technology for communication e1251 Assistive products and technology for communication e135 Products and technology for employment e1350 General products and technology for employment e1351 Assistive products and technology for employment e150 Design, construction and building products and technology of buildings for public use e1500 Design, construction and building products and technology for entering and exiting buildings for public use e1501 Design, construction and building products and technology for gaining access to facilities inside buildings for public use e1502, Design, construction and building products and technology for way finding, path routing and designation of locations in building for public use e155 Design, construction and building products and technology of buildings for private use e1550 Design, construction and building products and technology for entering and exiting of buildings for private use ( ) ( )
Environmental factors Short List of ENVIRONMENT e1551 Design, construction and building products and technology for gaining access to facilities in buildings for private use e1552 Design, construction and building products and technology for way finding, path routing and designation of locations in buildings for private use e165 Assets e1650 Financial Assets e1651 Tangible Assets e1652 Intangible Assets ( ) ( ) e2 NATURAL ENVIRONMENT AND HUMAN-MADE CHANGES TO ENVIRONMENT e210 Physical geography e2100 Land forms e2101 Bodies of water e3 SUPPORT AND RELATIONSHIPS e310 Immediate family e315 Extended family e320 Friends e325,,,, Acquaintances, peers, colleagues, neighbours and community members e340 Personal care providers and personal assistants e355 Health professionals e360 Other professionals e4 Attitudes e410 Individual attitudes of immediate family members e420 Individual attitudes of friends e425,,, Individual attitudes of acquaintances, peers, colleagues, neighbours and community members e440 Individual attitudes of personal care providers and personal assistants e450 Individual attitudes of health professionals e455 Individual attitudes of other professionals e460 Societal attitudes e5, SERVICES, SYSTEMS AND POLICIES e515, Architecture and construction services, systems and policies e5150 Architecture and construction services e5151 Architecture and construction systems e5152 Architecture and construction policies e525, Housing services, systems and policies e5250 Housing services e5251 Housing systems e5252 Housing policies
Environmental factors Short List of ENVIRONMENT e535, Communication services, systems and policies e5350 Communication services e5351 Communication systems e5352 Communication policies e540, Transportation services, systems and policies e5400 Transportation services e5401 Transportation systems e5402 Transportation policies e550, Legal services, systems and policies e5500 Legal services e5501 Legal systems e5502 Legal policies e555, Associations and organizational services, systems and policies e5550 Associations and organizational services e5551 Associations and organizational systems e5552 Associations and organizational policies e570, Social security services, systems and policies e5700 Social security services e5701 Social security systems e5702 Social security policies e575, General social support services, systems and policies e5750 General social support services e5751 General social support systems e5752 General social support policies e580, Health services, systems and policies e5800 Health services e5801 Health systems e5802 Health policies e590, Labour and employment services, systems and policies e5900 Labour and employment services e5901 Labour and employment systems e5902 Labour and employment policies ( ) ( ) ANY OTHER ENVIRONMENTAL FACTORS