Use our readymade template to create your Upper Extremity Functional Index (UEFI) assessment tool
Create your care assessments
| UEFI score | Proposed treatment |
|---|---|
| 0-20 | Severe difficulty or unable to perform activities |
| 21-40 | Moderate to quite a bit of difficulty |
| 41-60 | Little to moderate difficulty |
| 61-80 | Little difficulty |
| 81-100 | No difficulty |
- Prebuilt template with UEFI scoring to assess the level of difficulty an individual has with their upper limb
- 20-item questionnaire that scores each item from “0” (unable to perform activity) to “4” (no difficulty)
- Real-time calculation of UEFI Score based on the form responses
- Collect patient data and other sensitive healthcare data using our HIPAA compliant online assessment forms
- Compare the scores from the initial screening with that of the followup to track the progression of the patient's upper limb functionality
Collect responses from your patients
| Patient ID | 1004 |
| Patient Name | John W |
| Patient Email | johnw@ymail.com |
| Patient Phone Number | 0987654321 |
| Doctor's Name | Dr. Smith |
| Location | New York |
| 1. Any of your usual work, housework, or school activities | No difficulty |
| 2. Your usual hobbies, recreational or sporting activities | A little bit of difficulty |
| 3. Lifting a bag of groceries to waist level | Moderate difficulty |
| 4. Lifting a bag of groceries above your head | Quite a bit of difficulty |
| 5. Grooming your hair | Extreme difficulty or unable to perform activity |
| 6. Pushing up on your hands (eg from bathtub or chair) | No difficulty |
| 7. Preparing food (eg. peeling, cutting) | A little bit of difficulty |
| 8. Driving | Moderate difficulty |
| 9. Vacuuming, sweeping or raking | Quite a bit of difficulty |
| 10. Dressing | Extreme difficulty or unable to perform activity |
| 11. Doing up buttons | No difficulty |
| 12. Using tools or appliances | A little bit of difficulty |
| 13. Opening doors | Moderate difficulty |
| 14. Cleaning | Quite a bit of difficulty |
| 15. Tying or lacing shoes | Extreme difficulty or unable to perform activity |
| 16. Sleeping | No difficulty |
| 17. Laundering clothes (eg. washing, ironing, folding) | A little bit of difficulty |
| 18. Opening a jar | Moderate difficulty |
| 19. Throwing a ball | Quite a bit of difficulty |
| 20. Carrying a small suitcase with your affected limb | Extreme difficulty or unable to perform activity |
| UEFI score | 45 |
- Allow patients to fill in their details such as patient id, name, email etc in the UEFI assessment form
- Send an email invitation with a secure link for patients to complete their UEFI assessment form prior to their visit
- Allow patients to save their progress and complete their UEFI assessment form at a later time without losing any responses
- Set up an email template for your UEFI assessment and automatically send invitation emails to multiple patients with ease
- Send a confirmation email to the patients with their UEFI score, diagnosis, next steps when they submit their UEFI assessment
Track patient responses in Google Sheets
| A | B | C | D | E | |
|---|---|---|---|---|---|
| 1 | Name | Question | Answer | Score | Total Score |
| 2 | John W | 1. Any of your usual work, housework, or school activities | No difficulty | 4 | 45 |
| 3 | John W | 2. Your usual hobbies, recreational or sporting activities | A little bit of difficulty | 3 | 45 |
| 4 | John W | 3. Lifting a bag of groceries to waist level | Moderate difficulty | 2 | 45 |
| 5 | John W | 4. Lifting a bag of groceries above your head | Quite a bit of difficulty | 1 | 45 |
| 6 | John W | 5. Grooming your hair | Extreme difficulty or unable to perform activity | 0 | 45 |
| 7 | John W | 6. Pushing up on your hands (eg from bathtub or chair) | No difficulty | 4 | 45 |
| 8 | John W | 7. Preparing food (eg. peeling, cutting) | A little bit of difficulty | 3 | 45 |
| 9 | John W | 8. Driving | Moderate difficulty | 2 | 45 |
| 10 | John W | 9. Vacuuming, sweeping or raking | Quite a bit of difficulty | 1 | 45 |
| 11 | John W | 10. Dressing | Extreme difficulty or unable to perform activity | 0 | 45 |
| 12 | John W | 11. Doing up buttons | No difficulty | 4 | 45 |
| 13 | John W | 12. Using tools or appliances | A little bit of difficulty | 3 | 45 |
| 14 | John W | 13. Opening doors | Moderate difficulty | 2 | 45 |
| 15 | John W | 14. Cleaning | Quite a bit of difficulty | 1 | 45 |
| 16 | John W | 15. Tying or lacing shoes | Extreme difficulty or unable to perform activity | 0 | 45 |
| 17 | John W | 16. Sleeping | No difficulty | 4 | 45 |
| 18 | John W | 17. Laundering clothes (eg. washing, ironing, folding) | A little bit of difficulty | 3 | 45 |
| 19 | John W | 18. Opening a jar | Moderate difficulty | 2 | 45 |
| 20 | John W | 19. Throwing a ball | Quite a bit of difficulty | 1 | 45 |
| 21 | John W | 20. Carrying a small suitcase with your affected limb | Extreme difficulty or unable to perform activity | 0 | 45 |
- Export patient responses including the calculated UEFI score to Google Sheets for easy record-keeping
- Export individual points for each item to Google Sheets for data manipulation and analysis for comprehensive insights
- Use pre-built reports to easily keep track of patient progress over time and monitor changes in their upper limb functionality
- Receive a copy of the response and the calculated UEFI score by email whenever a patient submits their UEFI assessment
- Use data in Google Sheets to integrate with external EHR systems for seamless data transfer
HIPAA compliance
| Patient ID: | 1004 |
| Patient Name: | ****** |
| Patient Email: | ****** |
| Patient Phone Number: | ****** |
| Doctor's Name: | Dr. Smith |
| Location: | New York |
| 1. Any of your usual work, housework, or school activities: | No difficulty |
| 2. Your usual hobbies, recreational or sporting activities: | A little bit of difficulty |
| 3. Lifting a bag of groceries to waist level: | Moderate difficulty |
| 4. Lifting a bag of groceries above your head: | Quite a bit of difficulty |
| 5. Grooming your hair: | Extreme difficulty or unable to perform activity |
| 6. Pushing up on your hands (eg from bathtub or chair): | No difficulty |
| 7. Preparing food (eg. peeling, cutting): | A little bit of difficulty |
| 8. Driving: | Moderate difficulty |
| 9. Vacuuming, sweeping or raking: | Quite a bit of difficulty |
| 10. Dressing: | Extreme difficulty or unable to perform activity |
| 11. Doing up buttons: | No difficulty |
| 12. Using tools or appliances: | A little bit of difficulty |
| 13. Opening doors: | Moderate difficulty |
| 14. Cleaning: | Quite a bit of difficulty |
| 15. Tying or lacing shoes: | Extreme difficulty or unable to perform activity |
| 16. Sleeping: | No difficulty |
| 17. Laundering clothes (eg. washing, ironing, folding): | A little bit of difficulty |
| 18. Opening a jar: | Moderate difficulty |
| 19. Throwing a ball: | Quite a bit of difficulty |
| 20. Carrying a small suitcase with your affected limb: | Extreme difficulty or unable to perform activity |
| UEFI score: | 45 |
| UEFI score: | 45 |
- Create a HIPAA compliant UEFI assessment form to safely collect, store and access patient responses
- Mark fields as Protected Health Information (PHI) to secure sensitive patient data and limit access to PHI
- Automatically mask PHI fields when exporting UEFI form responses to Google Sheets and sending them on email
- Prepopulate patient details in UEFI assessments by creating secure prefill links without exposing PHI
- Limit access to patient data only for authorized personnel and minimize the risk of data breaches
These reviews are reproduced without modification from Google Workspace Marketplace.
July 23, 2023
I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!
— Sol Evans
October 31, 2023
We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!
— Chris Henesy
February 16, 2024
Does not work
— Myles Sicuro
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
November 27, 2023
Yeah this is good for all
— luqman Khan
July 10, 2023
We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.
— Joan S