| 1. Can you take a shower or bath without help? |
Yes—1 point, No—0 point |
| 2. Can you ascend the stairs without help? |
Yes—1 point, No—0 point |
| 3. Can you take care of all shopping needs independently? |
Yes—1 point, No—0 point |
| 4. How is the self-view of your nutritional status? |
good—1 point, bad—0 point |
| 5. Do you take more than 3 prescription drugs per day? |
No—1 point, Yes—0 point |
| 6. What year, month and day is this? |
correct answer – 1 point, incorrect answer – 0 point |
| 7. Have you dropped many of your activities and interests? |
No—1 point, Yes—0 point |
| Total points |
( ) /7 points |
