Function Tracker
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Function Tracker
Please state five functional goals that are measurable (ie. walk a mile without pain, get out of bed without pain, sit in a chair for an hour without pain). How close are you to 100% for your stated goals at evaluation? Please provide the percentage next to the stated goal.Example: I will walk one mile without pain in my back like I did before. Current status: 60%.
Goal 1
*
Current Status for Goal 1
*
Percentage of normal, ex 60%
Goal 2
*
Current Status for Goal 2
*
Percentage of normal, ex 60%
Goal 3
*
Current Status for Goal 3
*
Percentage of normal, ex 60%
Goal 4
*
Current Status for Goal 4
*
Percentage of normal, ex 60%
Goal 5
*
Current Status for Goal 5
*
Percentage of normal, ex 60%
Next Steps
Please rewrite the goals free hand without your current status percentage, post this on your bathroom mirror, and sign the bottom. Goals are 120% to 140% more likely to be achieved when written down and are seen in plain sight.
Submit
Should be Empty: