| Name of patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date. . . . . . . . . . . . . . . . | |||
|---|---|---|---|
| This form may help you assess the functional capabilities of your older patients. The data can be collected by a nurse from the patient or from an informant such as a family member or other caregiver (I = independent; A = assistance required; D = dependent) | |||
| Obtained from | Activity | Guidelines for assessment | |
| Patient | Informant | ||
| I A D | I A D | Using telephone | I = Able to look up numbers, dial telephone, and receive and make calls without help |
| A = Able to answer telephone or dial operator in an emergency, but needs special telephone or help in getting numbers and/or dialing | |||
| D = Unable to use telephone | |||
| I A D | I A D | Traveling | I = Able to drive own car or travel alone on buses or in taxis |
| A = Able to travel, but needs someone to travel with | |||
| D = Unable to travel | |||
| I A D | I A D | Shopping | I = Able to take care of all food and all clothes shopping with transportation provided |
| A = Able to shop, but needs someone to shop with | |||
| D = Unable to shop | |||
| I A D | I A D | Preparing meals | I = Able to plan and cook full meals |
| A = Able to prepare light foods, but unable to cook full meals alone | |||
| D = Unable to prepare any meals | |||
| I A D | I A D | Housework | I = Able to do heavy housework (i.e. scrub floors) |
| A = Able to do light housework, but needs help with heavy tasks | |||
| D = Unable to do any housework | |||
| I A D | I A D | Taking medicine | I = Able to prepare and take medications in the right dose at the right time |
| A = Able to take medications, but needs reminding or someone to prepare them | |||
| D = Unable to take medications | |||
| I A D | I A D | Managing money | I = Able to manage buying needs (i.e. write checks, pay bills) |
| A = Able to manage daily buying needs, but needs help managing checkbook and/or paying bills | |||
| D = Unable to handle money | |||
Adapted with permission from: Lawton MP, Brody EM. Gerontologist 1969;9:179–86. 1969 © The Gerontological Society of America.