Please answer these questions using the numbers 1-4 as defined for each question. In the last three months how often have you participated in:
1. Preparing main meals
2. Washing up
1 = never‚ 2 = <1 time per week‚ 3 = 1-2 times per week‚ 4 = most days
3. Washing clothes
4. Light housework
5. Heavy housework
6. Local shopping 7. Social outings
8. Walking outside >15 min
9. Actively pursuing hobby
10. Driving car / bus travel
1 = never‚ 2 = 1-2 times in 3 months‚ 3 = 3-12 times in 3 months‚ 4 = >1 time per week
In the last six months how often have you participated in:
11. Outings / car rides
1 = never‚ 2 = 1-2 times in 6 months‚ 3 = 3-12 times in 6 months‚ 4 = >1 time per week
12. Gardening
13. Household / car maintenance
1 = never‚ 2 = light‚ 3 = moderate‚ 4 = all necessary
14. Reading books
1 = none‚ 2 = 1 in 6 months‚ 3 = <1 in 2 weeks‚ 4 = > 1 in 2 weeks
15. Gainful work
1 = none‚ 2 = <10 hrs per week‚ 3 = 10-30 hrs per week‚ 4 = > 30 hrs per week
Total score: __________ (maximum 60)
This instrument can be found pages 14-15 of Compendium of Clinical Measures for Community Rehabilitation‚ available online at: http://www.health.qld.gov.au/qhcrwp/docs/clinical_measure.pdf
Holbrook‚ M & Skilbeck‚ CE 1983‚ „An activities index for use with stroke patients‟‚ Age Ageing‚ vol. 12‚ pp. 166–170.