DATE:           TIME (24hr): 

1. Ability to use phone, television, internet, communication modalities
[]   0 = Operates telephone on own initiative, looks up and dials numbers, finds desired TV shows, uses internet.
[]   1 = Dials a few well known numbers, difficulty using TV-remote, trouble with internet use.
[]   2 = Answers telephone but does not dial, watches TV passively, no internet use.
[]   3 = Does not use telephone at all (could if necessary), watches TV, unable to discuss content.
[]   4 = Incapable of using telephone, does not watch TV.

2. Shopping: clothes, household items, groceries
[]   0 = Takes care of all shopping needs independently.
[]   1 = Shops independently for small purchases.
[]   2 = Needs to be accompanied on any shopping trip.
[]   3 = Completely unable to shop.

3. Food (If never prepared meals, note and score according to related abilities)
[]   0 = Plans, prepares, and serves adequate, balanced meals independently.
[]   1 = Prepares adequate meals if supplied with ingredients.
[]   2 = Heats and serves prepared meals, or prepares meals.
[]   3 = Needs to have meals prepared and served.

4. Housekeeping, cleaning, laundry, taking out garbage, litter
[]   0 = Maintains house, appropriate involvement for keeping order, can do personal laundry, good level of cleanliness.
[]   1 = Performs light daily tasks such as dish washing, bed making, laundering small items, rinsing socks.
[]   2 = Performs light daily tasks but cannot do laundry, maintain acceptable level of cleanliness without assistance.
[]   3 = Needs help with all home maintenance tasks.
[]   4 = Is unable to participate in any housekeeping tasks.

5. Proper and safe use of old, new appliances in home
[]   0 = Can heat water, cook food, turn off stove after use, use dishwasher, washing machine.
[]   1 = Can use familiar appliances, difficulty with new things, can use on-off controls, heat simple items, e.g., use toaster.
[]   2 = Cannot use appliances safely, turn off stove, use on-off controls.

6. Mode of Transportaion, traveling out of neighborhood, driving, taking public transport
[]   0 = Travels independently on public transportation or drives own car.
[]   1 = Arranges own travel via taxi, but does not otherwise use public transportation.
[]   2 = Travels on public transportation when assisted or accompanied by another.
[]   3 = Travel limited to taxi or automobile with assistance of another.

7. Remembering appointments, family activities, holidays, responsibility for own medication
[]   0 = Makes and keeps appointments, arranges activities for family, vacation. Is responsible for taking medication dosages at correct time.
[]   1 = Forgets scheduled appointments, participates less in activity planning. Takes medication if prepared in advance in separate dosages.
[]   2 = Is not capable of making appointments, planning activities, dispensing own medication.

8. Ability to handle finances, write checks, pay bills, balance checkbook, assemble taxes
[]   0 = Manages financial matters independently (budgets, writes checks, pays rent and bills, balances checkbook, does banking), keeps track of income, assembles tax records. Makes good financial decisions, buys appropriate gifts.
[]   1 = Manages daily purchases, but needs help with major purchases, business affairs, taxes.
[]   2 = Incapable of handling money.

9. Toilet, proper use of bathroom
[]   0 = Cares for self at toilet completely, no incontinence. Cares for self at toilet, no incontinence.
[]   1 = Needs to be reminded or needs help in cleaning self, may have rare accidents.
[]   2 = Soiling or wetting while asleep more than once a week, usually continent.
[]   3 = Soiling or wetting while awake more than once a week, frequently continent.
[]   4 = No control of bowels or bladder, fully incontinent.

10. Feeding
[]   0 = Eats without assistance at meal time.
[]   1 = Eats with minor assistance, needs help serving food, cleaning up after meals.
[]   2 = Feeds self with moderate assistance and is untidy.
[]   3 = Requires extensive assistance for all meals, may be fed by someone else.
[]   4 = Does not feed self at all and resists efforts of others to feed him/her.

11. Dressing
[]   0 = Dresses, undresses, and selects clothes from own wardrobe.
[]   1 = Dresses and undresses self, with minor assistance.
[]   2 = Needs moderate assistance in dressing or selection of clothes.
[]   3 = Needs major assistance in dressing, but cooperates with efforts of others to help.
[]   4 = Completely unable to dress self and resists efforts of others to help.

12. Grooming (neatness, hair, nails, hands, face, clothing)
[]   0 = Always neatly dressed, well-groomed, without assistance, cuts own fingernails.
[]   1 = Grooms self adequately with occasional minor assistance, e.g., in shaving.
[]   2 = Needs moderate and regular assistance, supervision in grooming, brushing, combing hair.
[]   3 = Needs total grooming care, but can remain well-groomed after help from others.
[]   4 =Actively negates all efforts of others to maintain grooming.

13. Physical Ambulation
[]   0 = Goes about grounds or city.
[]   1 = Ambulates within residence or about one-block distance.
[]   2 = Ambulates with assistance of another person, railing, cane, walker, or wheelchair.
[]   3 = Sits unsupported in chair or wheelchair, but cannot propel self without help.
[]   4 = Bedridden more than half the time.

14. Bathing
[]   0 = Bathes self (tub, shower, sponge bath) without help or reminding.
[]   1 = Bathes self with help in getting in and out of tub. May need reminding.
[]   2 = Washes face and hands only, but cannot bathe rest of body.
[]   3 = Does not wash self, but is cooperative with those who bathe him or her.
[]   4 = Does not try to wash self and resists efforts to keep him or her clean.

15. Global Function
[]   0 = Able to live independently without assistance.
[]   1 = Because of memory problems, requires at least weekly visit by outside support person.
[]   2 = Requires daily help to function, needs caregiver, can be left alone for less than one hour.
[]   3 = Requires help in all areas of function during day; cannot be left alone or requires medication for behavioral control.

  0 -    5     normal, depending on age, education, complaints
  6 -  10     possible impairment
11 -  20     mild impairment
21 -  30     moderate impairment
31 -  40     severe impairment
41 -  50     profound/complete impairment

Note that this is a continuum of approximate descriptions, not a rigid classification.

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