Item Label | Question to patient | Question to key informant | Observationa | Standard task (done with usual help) | Global response and score |
---|---|---|---|---|---|
Self Care | |||||
Dressing top | Do you get your top dressed? | Does…get his/her top dressed? | Top adequately dressed? | Take off top and put it back on. | OK by self [0] |
OK with Help [0] | |||||
Not OK [1] | |||||
Mobility (indoors) | Do you get around in your home OK? | Does…get around in the home OK? | N/A | Mobilise around objects in the room. | OK by self [0] |
OK with Help [0] | |||||
Not OK [1] | |||||
Domestic Life | |||||
Groceries | Do you get your groceries? | Does…get his/her groceries? | Adequate groceries present? | Clarify situation through discussion. | OK by self [0] |
OK with Help [0] | |||||
Not OK [1] | |||||
Laundry | Do you get your clothes laundered regularly? | Does…get clothes laundered regularly? | Absence of dirty laundry? | Clarify situation through discussion. | OK by self [0] |
OK with Help [0] | |||||
Not OK [1] |