Worksheet used in elementary short course for the clinical application of ICF

1. INTERPROFESSIONAL CARE FRAMEWORK FOR CONTINUOUS INTERPROFESSIONAL CARE
(based on the WHO’s International Classification of Functioning, Disability and Health) Name:
HEALTH CONDITION/S
IMPAIRMENT (BODY FUNCTIONS AND STRUCTURES) ACTIVITY LIMITATION & PARTICIPATION RESTRICTION
Component & Domains Assessment / Change in … Action steps Responsible person(s) Component & Domains Performance and capacity Action steps Responsible person(s)
Mental functions &
structures of nervous
system
Learning and applying
knowledge
Pain & Sensory functions,
structures of the eye, ear
& related structures &
pain
General tasks and
demands (planning,
financial management)
Systems and structures
involved in voice &
speech
Communication (verbal
and non-verbal)
Functions and structures
of cardiovascular,
haematological,
immunological &
respiratory systems
Mobility (indoors,
outdoors, transport)
Functions and structures
of digestive, metabolic &
endocrine systems
Self-care (personal,
health maintenance)
Functions and structures
of genitourinary &
reproductive systems
Domestic life
Functions & structures of
skin & related functions
Interpersonal interactions
and relationships (family,
intimate, informal)
Neuromuscular &
movement-related
functions & structures
related to movement
Major life areas
(education, employment)
Community, social and
civic life (community,
recreation, leisure,
religion)

2. ENVIRONMENTAL FACTORS PERSONAL FACTORS
Component & Domains Barriers & Facilitators Action steps Responsible person(s) Component & Domains Positive / negative Action steps Responsible person(s)
Products & technology
Natural environment &
human-made changes to
environment
Support & relationships
(incl. genogram & current
relationships
Attitudes
Services, systems &
policies
PRIORITY LIST
Action Desired outcome Responsible persons Notes:
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