Appendix 1.

Activities of Daily Living Assessment

Please rate your need for assistance with performing the following activities by checking the appropriate box
ACTIVITIES OF DAILY LIVING	INSTRUMENTAL ACTIVITIES OF DAILY LIVING
BATHING	SHOPPING
❑ Can perform without assistance	❑ Can perform without assistance
❑ Can perform with assistance	❑ Can perform with assistance
❑ Cannot perform (with assistance)	❑ Cannot perform (with assistance)
DRESSING	PREPARING MEALS
❑ Can perform without assistance	❑ Can perform without assistance
❑ Can perform with assistance	❑ Can perform with assistance
❑ Cannot perform (with assistance)	❑ Cannot perform (with assistance)
USING THE TOILET	USING THE TELEPHONE
❑ Can perform without assistance	❑ Can perform without assistance
❑ Can perform with assistance	❑ Can perform with assistance
❑ Cannot perform (with assistance)	❑ Cannot perform (with assistance)
TRANSFERRING	MANAGING MEDICATIONS
❑ Can perform without assistance	❑ Can perform without assistance
❑ Can perform with assistance	❑ Can perform with assistance
❑ Cannot perform (with assistance)	❑ Cannot perform (with assistance)
CONTINENCE	MANAGING FINANCES
❑ Can perform without assistance	❑ Can perform without assistance
❑ Can perform with assistance	❑ Can perform with assistance
❑ Cannot perform (with assistance)	❑ Cannot perform (with assistance)
EATING
❑ Can perform without assistance
❑ Can perform with assistance
❑ Cannot perform (with assistance)