IADL	Independent	Dependent
Mode of transportation	Travels independently or arranges own travel via taxi or travels on public transportation when assisted or accompanied by another	Travel limited to taxi or automobile with assistance of another or does not travel at all
Food preparation	Plans, prepares, and serves adequate meals independently	Prepares adequate meals if supplied with ingredients or needs to have meals prepared and served
Responsibility for own medications	Is responsible for taking medication in correct dosages at correct time	Takes responsibility if medication is prepared in advance in separate dosages, or not capable of dispensing own medication
Laundry	Does personal laundry completely or launders small items	All laundry must be done by others
Ability to use telephone	Operates telephone on own initiative, dials a few well‐known numbers, or answers telephone but does not dial	Does not use telephone at all
Ability to handle finances	Manages financial matters independently, or manages day‐to‐day purchases, but needs help with banking, major purchases, etc	Incapable of handling money
Shopping	Takes care of all shopping needs independently	Shops independently for small purchases or needs to be accompanied on any shopping trip, or completely unable to shop
Housekeeping	Maintains house alone, performs light daily tasks, or performs light daily tasks but needs help with all home maintenance tasks	Does not participate in any housekeeping tasks

Note: IADL is instrumental activities of daily living. Number of impaired IADLs:________(Determined by assessment the aforementioned eight activities. If an individual is unable to perform an activity independently and requires assistance from others, it is to be considered as one impairment. The total number of impairments is calculated accordingly).