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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 needs for home care.

1. ABILITY TO USE TELEPHONE

3 Operates telephone on own initiative; looks up and dials numbers, etc.

2 Dials a few well known numbers

1 Answers telephone but does not dial

0 Does not use telephone at all __________

2. SHOPPING

3 Takes care of all shopping needs independently

2 Shops independently for small purchases

1 Needs to be accompanied on any shopping trip

0 Needs to have meals prepared and served __________

3. FOOD PREPARATION

3 Plans, prepares and serves adequate meals independently

2 Prepares adequate meals if supplied with ingredients

1 Heats and serves prepared meals, or prepares meals but does not maintain adequate diet

0 Needs to have meals prepared and served __________

4. HOUSEKEEPING

4 Maintains house alone or with occasional assistance (e.g., heavy-work domestic help)

3 Performs light daily tasks such as dish-washing and bed-making

2 Performs light daily tasks but cannot maintain acceptable level of cleanliness

1 Needs help with all home maintenance tasks

0 Does not participate in any housekeeping tasks __________

5. LAUNDRY

2 Does personal laundry completely

1 Launders small items; rinses socks, stockings, etc.

0 All laundry must be done by others __________

6. MODE OF TRANSPORTATION

4 Travels independently on public transportation or drives own car

3 Arranges own travel via taxi, but does not otherwise use public transportation

2 Travels on public transportation when assisted or accompanied by another

1 Travel limited to taxi or automobile, with assistance of another

0 Does not travel at all __________

7. RESPONSIBILITY FOR OWN MEDICATION

2 Is responsible for taking medication in correct dosages at correct time

1 Takes responsibility if medication is prepared in advance in separate dosages

0 Is not capable of dispensing own medication __________

8. ABILITY TO HANDLE FINANCES

2 Manages financial matters independently (budgets, write checks, pays rent and bills, goes to bank, collects and keeps track of income

1 Manages day-to-day purchases, but needs help with banking, major purchases, etc.

0 Incapable of handling money __________

 

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.