Assistance with activities of daily living
Eating: None‚ A little‚ A lot‚ Spoon-feed; intravenous tube
Walking (with cane or walker if used): None‚ A little‚ A lot‚ Does not walk
Mobility (going outside and getting about with wheelchair‚ etc.‚ if used): None‚ A little‚ A lot‚ Is housebound)
Bathing (include getting supplies‚ supervising): None‚ A little‚ A lot‚ Must be bathed
Dressing (include help in selecting clothes): None‚ A little‚ A lot‚ Must be dressed
Toileting (include help with clothes‚ cleaning‚ or help with ostomy‚ catheter): None‚ A little‚ A lot‚ Uses bedpan or unable to care for ostomy/ catheter)
Grooming (shaving for men‚ hair- dressing for women‚ nails‚ teeth): None‚ A little‚ A lot‚ Must be groomed)
Adaptive tasks (managing money/ possessions; telephoning‚ buying newspaper‚ toilet articles‚ snacks): None‚ A little‚ A lot‚ Cannot manage)
Degree of disability
Communication (expressing self): None‚ A little‚ A lot‚ Does not communicate)
Hearing (with aid if used): None‚ A little‚ A lot‚ Does not seem to hear)
Sight (with glasses‚ if used): None‚ A little‚ A lot‚ Does not see)
Diet (deviation from normal): None‚ A little‚ A lot‚ Fed by intravenous tube)
In bed during day (ordered or self- initiated): None‚ A little‚ A lot‚ Most/all of time
Incontinence (urine/feces‚ with catheter or prosthesis‚ if used): None‚ Sometimes‚ Frequently (weekly +)‚ Does not control)
Medication: None‚ Sometimes‚ Daily; taken orally‚ Daily; injection; (+ oral if used))
Degree of special problems
Mental confusion: None‚ A little‚ A lot‚ Extreme)
Uncooperativeness (combats efforts to help with care): None‚ A little‚ A lot‚ Extreme)
Depression: None‚ A little‚ A lot‚ Extreme)
