For each area of functioning listed below‚ check description that applies. (The word “assistance” means supervision‚ direction‚ or personal assistance.)
Bathing—either sponge bath‚ tub bath‚ or shower
___ Receives no assistance (gets in and out of tub by self if tub is usual means of bathing)
___ Receives assistance in bathing only one part of the body (such as back or a leg)
___ Receives assistance in bathing more than one partof the body (or not bathed)
Dressing—gets clothes from closets and drawers—including underclothes‚ outer garments and using fasteners (including braces if worn)
___ Get clothes and gets completely dressed without assistance
___ Gets clothes and gets dressed without assistance except for assistance in tying shoes
___ Receives assistance in getting clothes or in getting dressed‚or stays partly or completelyundressed
Toileting—going to the “toilet room” for bowel and urine elimination; cleaning self after elimination‚ and arranging clothes
___ Goes to “toilet room‚” cleans self‚ and arranges clothes without assistance (may use object for support such as cane‚ walker‚ or wheelchair and may manage night bedpan or commode‚ emptying same in morning)
___ Receives assistance in going to “toilet room” or in cleansing self or in arranging clothes after elimination or in use of night bedpan or commode
___ Doesn’t go to room termed “toilet” for the elimination process
Transfer—
___ Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walker)
___ Moves in and out of bed or chair with assistance
___ Doesn’t get out of bed
Continence—
___ Controls urination and bowel movement completely by self
___ Has occasional “accidents”
___ Supervision helps keep urine or bowel control; catheter is used‚ or is incontinent
Feeding—
___ Feeds self without assistance
___ Feeds self except for getting assistance in cutting meat or buttering bread
___ Receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids
