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Instructions: Write in the appropriate value number on the score lines provided to the right of the responses. Add the value numbers to obtain total score. Lower scores indicate higher need for home care.

1. TOILET

4 Cares for self at toilet completely, no incontinence

3 Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents

2 Soiling or wetting while asleep, more than once a week

1 Soiling or wetting while awake, more than once a week

0 No control of bowels or bladder __________

2. FEEDING

4 Eats without assistance

3 Eats with minor assistance at meal times, with help preparing food or with help in cleaning up after meals

2 Feeds self with moderate assistance and is untidy

1 Requires extensive assistance for all meals

0 Does not feed self at all and resists efforts of others to feed him __________

3. DRESSING

4 Dresses, undressed and selects clothes from own wardrobe

3 Dresses and undresses self, with minor assistance

2 Needs moderate assistance in dressing or selection of clothes

1 Needs major assistance in dressing but cooperated with efforts of other to help

0 Completely unable to dress self and resists efforts of others to help __________

4. GROOMING (neatness, hair, nails, hands, face, clothing)

4 Always neatly dressed and well-groomed, without assistance

3 Grooms self adequately, with occasional minor assistance, e.g., in shaving

2 Needs moderate and regular assistance or supervision in grooming

1 Needs major assistance in dressing but cooperates with efforts of others to help

0 Actively negates all efforts to others to maintain grooming __________

5. PHYSICAL AMBULATION

4 Goes about grounds or city

3 Ambulates within residence or about one block distant

2 Ambulates with assistance of (check one): ____another person, ____ railing, ____ cane, ____ walker,

or ____ wheelchair: ____ gets in and out without help ____ needs help in getting in and out

1 Sits unsupported in chair or wheelchair, but cannot propel self without help

0 Bedridden more than half the time __________

6. BATHING

4 Bathes self (tub, shower, sponge bath) without help

3 Bathes self, with help in getting in and out of tub

2 Washes face and hands only, but cannot bathe rest of body

1 Does not wash self but is cooperative with those who bathe him

0 Does not travel at all __________

 

TOTAL SCORE __________

Adapted from: Lawton MP, Brody EM. Assessment of Older People: Self-Maintaining and Instrumental Activities of Daily Living. Gerontologist 9(1969):179-186.