Table 5. Functional Assessment Questionnaire
In the Past 4 Weeks, Did the Subject Have Any Difficulty or Need Help With:Not ApplicableNormalHas Difficulty, But Does by SelfRequires AssistanceDependent
1. Writing checks, paying bills or balancing a checkbook
2. Assembling tax records, business affairs, or other papers
3. Shopping alone for clothes, household necessities, or groceries
4. Playing a game of skill such as bridge or chess, working on a hobby
5. Heating water, making a cup of coffee, turning off the stove
6. Preparing a balanced meal
7. Keeping track of current events
8. Paying attention to and understanding a TV program, book, or magazine
9. Remembering appointments, family occasions, holidays, medications
10. Traveling out of the neighborhood, driving, or arranging to take public transportation
  • Adapted from Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323–9. 1982 © The Gerontological Society of America.