Last Name (Legal) First Name (Legal)
Preferred Name Last First DOB(dd-Mon-yyyy)
PHN ULI Same as PHN MRN
Administrative Gender Male Female
Non-binary/Prefer not to disclose (X) Unknown
Post COVID-19 Functional Status Scale
and Post COVID-19 Symptom Checklist
21820 (Rev2022-05)
This two-part tool is designed to identify rehabilitation and recovery needs of patients who have been diagnosed with or
suspected to have COVID-19. Any healthcare provider can administer this tool at any time during the patient’s journey.
Part 1: Post COVID-19 Functional Status Scale (PCFS)
How much is the patient currently affected in their everyday life by COVID-19?
Check the box beside the most accurate description and see below for appropriate resources and services.
Consider pre-existing conditions and whether there are changes from baseline (pre-COVID-19 infection) function.
No limitations = PCFS Score 0
No symptoms related to the COVID-19 infection.
Negligible limitations = PCFS Score 1
Can perform all usual duties/activities, although still has persistent symptoms e.g. cough, loss of taste/smell.
Slight limitations = PCFS Score 2
Occasionally needs to avoid or reduce usual duties/activities/work or needs to spread these over time due to
symptoms. May require occasional assistance to complete activities due to persistent symptoms e.g. minor
headache/fatigue, muscle aches.
Moderate limitations = PCFS Score 3
Unable to perform all usual duties/activities/work due to symptoms e.g. chest pain, moderate fatigue/brain fog,
nerve pain.
Severe limitations = PCFS Score 4
Unable to take care of oneself, is dependent on nursing care and/or assistance from another person due to
symptoms e.g. shortness of breath, severe fatigue/brain fog.
Practitioner Name Signature/Designation Date (dd-Mon-yyyy)
Page 1 of 3
Adapted from: Klok FA, Boon GJAM, Barco S, et al. The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after
COVID-19. Eur Respir J 2020; 56: 2001494 [https://doi.org/10.1183/13993003.01494-2020] is licensed under CC BY NC 4.0.
Healthcare providers are encouraged to factor in which resources and services are available in each situation to support
their patient’s unique needs. The majority of patients can self-manage with appropriate resources and supports.
Resources for ALL patients (PCFS Score 0-4)
Universal Self Care Resources should be shared with ALL patients as early as possible.
Getting Healthy After COVID-19: Resources for Patients
After COVID-19: Information and resources to help you recover
Targeted Resources (PCFS Score 2-3)
Services designed for groups of people with a common need.
Alberta Healthy Living Program’s Video Series for Patients
Personalized Resources (PCFS Score 3-4)
Individualized, multidisciplinary care designed to meet the unique needs of an individual.
Long COVID Patient Services
Additional Resources for Healthcare Providers
Recovery & Rehabilitation after COVID-19: Resources for Health Professionals
Information for Community Physicians
