A. Ability to use telephone |
1. Operates telephone on own initiative; looks up and dials numbers |
1 |
2. Dials a few well-known numbers |
1 |
3. Answers telephone but does not dial |
1 |
4. Does not use telephone at all |
0 |
B. Shopping |
1. Takes care of all shopping needs independently |
1 |
2. Shops independently for small purchases |
0 |
3. Needs to be accompanied on any shopping trip |
0 |
4. Completely unable to shop |
0 |
C. Food preparation |
1. Plans, prepares, and serves adequate meals independently |
1 |
2. Prepares adequate meals if supplied with ingredients |
0 |
3. Heats, serves, and prepares meals, or prepares meals, or prepares meals but does not maintain adequate diet |
0 |
4. Needs to have meals prepared and served |
0 |
D. Housekeeping |
1. Maintains house alone or with occasional assistance (e.g. ‘heavy work domestic help’) |
1 |
2. Performs light daily tasks, such as dish-washing, bed-making |
1 |
3. Performs light daily tasks but cannot maintain acceptable level of cleanliness |
1 |
4. Needs help with all home maintenance tasks |
1 |
5. Does not participate in any housekeeping tasks |
0 |
E. Laundry |
1. Does personal laundry completely |
1 |
2. Launders small items; rinses stockings, etc. |
1 |
3. All laundry must be done by others |
0 |
F. Mode of transportation |
1. Travels independently on public transportation or drives own car |
1 |
2. Arranges own travel via taxi, but does not otherwise use public transportation |
1 |
3. Travels on public transportation when accompanied by another |
1 |
4. Travel limited to taxi or automobile with assistance of another |
0 |
5. Does not travel at all |
0 |
G. Responsibility for own medications |
1. Is responsible for taking medication in correct dosages at correct time |
1 |
2. Takes responsibility if medication is prepared in advance in separate dosage |
0 |
3. Is not capable of dispensing own medication |
0 |
H. Ability to handle finances |
1. Manages financial matters independently (budgets, writes checks, pays rent, bills, goes to bank), collects and keeps track of income |
1 |
2. Manages day-to-day purchases, but needs help with banking, major purchases, etc. |
1 |
3. Incapable of handling money |
0 |
Scoring: for each category, circle the item description that most closely resembles the patient's highest functional level (either 0 or 1) |
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