Name:

Age/Sex/Civil Status:
Birthday:
Date of Assessment:
Attending Physician:

FUNCTIONAL STATUS

A. ACTIVITIES OF DAILY LIVING (KATZ Scale)

Present
Activity Description and Score
Score
¨ No assistance ( 2 )
Eating ¨ Needs assistance in cutting meat or buttering bread ( 1 )
¨ Needs assistance in eating or is fed intravenously (0)
¨ Gets clothes and dresses without assistance ( 2 )
Dressing ¨ Needs assistance in tying one’s shoes, in getting clothes or in getting dressed (1)
¨ Stays partly or completely undressed ( 0 )
¨ Bathes without assistance ( 2 )
Bathing ¨ Needs assistance only in bathing one part of the body (e.g. back) ( 1 )
¨ Needs assistance in bathing more than one part of the body or does not bathe ( 0 )
¨ Moves in and out of bed and chair without assistance; may use cane or walker ( 2 )
Transferring ¨ Needs assistance in moving in and out of bed or chair ( 1 )
¨ Does not get out of bed ( 0 )
¨ Goes to the bathroom, uses toilet, cleans self, arranges clothes, and goes out of the bathroom without
assistance; may use cane or walker for support; and may use bedpan or urinal at night ( 2 )
Toileting ¨ Needs assistance in going to the bathroom, using the toilet, cleaning self, arranging clothes or going
out of the bathroom ( 1 )
¨ Does not go to the bathroom to relieve bladder or bowel ( 0 )
¨ Controls bladder and bowel completely without occasional accidents ( 2 )
Continence ¨ Occasionally loses control of bladder and bowel ( 1 )
¨ Needs supervision to control bladder or bowel, requires use of a catheter, or is incontinent ( 0 )
TOTAL SCORE / 12
B. INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALES (LAWTON Scale)
Description and Score
Present
Activity Without help With some help Completely unable
Score
(2) (1) (0)

Meal Preparation   
Housework   
Laundry   
Taking of medications   
Traveling beyond walking distance   
Shopping   
Handling of Finances   
Use of the Telephone   
TOTAL SCORE / 16