Today's date:                 Time:

Patient's Initials:                    Patient Number:  

Study Number:                       Rater's Initials:

Instrumental ADLs

1. Ability to use phone                  0           1           2            3           4

2. Shopping                                  0           1           2            3                 

3. Food                                        0          1           2            3                

4. Housekeeping                          0           1           2            3           4

5. Laundry                                   0           1           2                                                                              

6. Mode of Transportaion            0           1           2            3

7. Responsibility for
          own medication                 0           1           2                                                                                 

8. Ability to handle finances         0           1           2   

Basic ADLs

9.Toilet                                        0           1           2            3           4  

10. Feeding                                  0           1           2            3           4                                

11. Dressing                                  0           1           2            3           4

12. Grooming                                0           1           2            3           4                                       

13. Physical Ambulation                 0           1           2            3           4

14. Bathing                                   0           1           2            3           4

15. Global Function                       0           1           2            3

TOTAL ADL SCORE    (Max = 50)    ________________