| In the Past 4 Weeks, Did the Subject Have Any Difficulty or Need Help With: | Not Applicable | Normal | Has Difficulty, But Does by Self | Requires Assistance | Dependent |
|---|---|---|---|---|---|
| 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.