DIST RU MET Ev htirtee- PP PSes & TAP DE MC-410 Le. BRISTOL ACTIVITIES OF DAILY LIVING SCALE (BADLS) This questionnaire is designed to reveal the everyday ability of people who have memory difficulties of one form or another. For euch activity (Nos, 1-20), statements ave refer to a different level of abi of the lust 2 weeks, tick the box that represents your relative's/friend's ability. Thinking Uf patient has never performed this activity: even whest well score ~ ¢ (Not Applicable). Only one box should be ticked for each activity. (fit doubs about which box to tick, choose the level of ability which represents their average performunce over the lust 2 weeks) 1. FOOD 4. DRINKING a. Selects and prepares food as a Drinks appropnately required b. Drinks appropriately with aids b. Able to prepare food if ingredients (beakeristraw etc) set out _ ¢ Does not drink appropriately [_} € Can prepare food if prompted step even with aids but attempts to by step 4. Has to have drink administered d_ Unable to prepare food even with (fed) prompting and supers e Not applicable Not applicable 5. DRESSING 2. EATING a. Selects appropriate clothing and dresses self a. Eats appropriately using correct b. Puts clothes on in wrong order cutlery b._ Eats appropriately if food made manageable and/or twses spoon c. Uses fingers to eat food d_ Needs to be fed 4 2, Not applicable and/or back to front and/or dirty clothing, Unable to dress self but moves limbs to assist Unable to assist and requires total dressing e. Not applicable BRINKS 6, HYGIENE a. Selects and prepares drinks as Aneel requied a Washes 1 7 a aly = b Can prepare drinks if ingcedients {7} aacependent left available b_ Cun wash self if given soap. flzonel, towel, ete c. Can wash self if prompted and Can prepare drinks uf prompted 7} Tse con supervised 4 Unable to make a drink even with d Unable to wash self and needs prompting and supervision Saree oO © Not applicable e, Not applicableRD x 7. TEETH a b a b c a e 9, TOILET/COMMODE 10. TRANSFERS BATH/SHOWER ‘Cleans own teeth/dentures regularly and independently Cleans teeth/dentures if given appropnate items Requires some assistance, toothpaste on brush, brush to mouth, ete Full assistance given Not applicable Bathes regularly and independently Needs bath to be drawn'shower turned on but washes independently ‘Needs supervision and prompting [7] to wash Torally dependent. needs full assistance Not applicable Uses toilet appropriately when required Needs to be taken to the toilet and ven assistance Incontinent of urine or faeces Incontinent of urine and faeces Not applicable Can get/in out of chait Can get into a chatr but needs help >) to get our Needs help getting out of a chair Totally dependent on being put into and lifted from chair Not applicable o 11, MOBILITY a. Walks independently b Walks with assistance. ie furniture, arm for support ©. Uses aids to mobilise. ie. frame, sticks. ete d. Unable to walk Not applicable 12, ORIENTATION - TIME a. Fally orientated to surrounds b. Unaware of time/dlay ete but seems unconcemed ¢. Repeatedly asks the time: day idate d Mixes up night and day e. Not applicable 13. ORIENTATION ~ SPACE a. Fully orientated to surrounclings Orientated to familiar surroundings only, ¢. Gets lost in home, needs renund- ing where bathroom is, ete 4. Does not recognise home as own or attempis to leave ce. Not applicable 14. COMMUNICATIONS Able to hold appropriate conversation b. Shows understanding and attempts to respond verbally with gestures Can make self understood but difficulty understanding others d. Does not respond to or comnyunicate with others 2, Not applicable ACTIVITIES OF DAILY LIVING QUESTIONNAIRE oOi o0e 15. TELEPHONE a. Uses telephone appropriately, including obtaining correct number b. Uses telephone if number given verbally visually or predialled ©. Answers telephone but does not make calls 4. Unable/unwilling to use telephone at all © Not applicable 16. HOUSEWORK/GARDENING a. Able to do housework ardening to previous standard b. Able to do housework/ardening but not to previous standard ¢ Limited participation even with a lot of supervision ¢. Unwalling/unable to participate in previous activities . Not applicable 17. SHOPPING a. Shops to previous standard b_ Only able to shop for 1 oF 2 items with or without a list ¢. Unable to shup alone, but participates when accompanied Unable to participate in shopping even when accompanied Not applicable 18. FINANCES a Responsible for own previous level b. Unable to write cheque but can sigh name and recognises money values ¢ Can sign name but unable to recognise money values d_ Unable to sign name or recounise money values e. Not applicable ances at ACTIVITIES OF DAILY LIVING QUESTIONNAIRE 20, TRANSPORT Q 19, GAMES/ HOBBIES a. Participates in pastimes/activities to previous standard b, Participates but needs instruction/ supervision =. ¢. Reluctant to join in. very slow. needs coaxing = d. No longer able or willing to yoin un W e. Not applicable a, Able fo drive, cycle or use public transport independently bb. Unable to drive but uses public transport or bike, etc ¢ Unable to use public transport alone dd, Unable/anwilling to use trans- port even when accompanied e, Not applicable Date ‘Thank you for taking the time to complete questionnaire.