Am Pac Form PDF Details

Pacific Standard Time (PST) is the standard time used in the states of California, Oregon, Washington, Nevada, and parts of Idaho. It is also daylight saving time for these states. This means that during the winter months, when the sun sets earlier, PST is in effect. However, during the summer months when the sun stays out later, PDT is in effect. There are pros and cons to each time zone - PST has shorter days in the winter but longer days in the summer while PDT has longer days in the winter but shorter days in the summer. So which one is better? That's up to you to decide!

QuestionAnswer
Form NameAm Pac Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesam pac 6 clicks pdf, boston am pac, boston ampac, boston university am pac

Form Preview Example

AM-PAC Generic Outpatient Basic Mobility Short Form

Boston University AM-PAC™

Generic Basic Mobility Outpatient Short Form

Please check the box that reflects your (the patient’s) best answer to each question.

 

 

 

 

 

A

 

 

 

How much difficulty do you currently have…

Unable

 

A Lot

 

None

 

 

 

 

Little

 

 

 

 

 

 

 

 

 

1.Bending over from a standing position to pick up a piece of clothing from the floor without holding onto anything?

2.Standing up from a low, soft couch?

3.Taking a 1-mile brisk walk, without stopping to rest?

4.Running for 5 minutes on even surfaces?

5.Walking several blocks?

6.Walking up and down steep unpaved inclines (e.g., steep gravel driveway)?

7.Running a short distance, such as to catch a bus?

8.Carrying something in both arms while climbing a flight of stairs (e.g., laundry)?

9.Going up and down a flight of stairs outside, without using a handrail?

10.Making sharp turns when running fast?

11.Taking part in strenuous activities (e.g., running 3 miles, swimming half mile, etc.)?

12.Standing up from an armless straight chair (e.g., dining room chair)?

13.Walking on an uneven surface (e.g., grass, dirt road or sidewalk, brick walkways, sidewalks with curb and driveways cuts)?

14.Walking around one floor of their home, taking into consideration thresholds, doors, furniture, and a variety of floor coverings?

15.Doing light housework (e.g., dusting, minor sweeping)?

16.Moving up in bed (e.g., reposition self)?

17.Getting into and out of a car/taxi (sedan)?

18.Cleaning up spills on the floor with a mop?

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Raw Score:

 

CMS 0-100% Score:

 

Standardized Score:

 

CMS Modifier:

 

AM-PAC Short Form Manual (v. 3)

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