Check if present

Assessment
(score is highest consecutive level of disability)

1

No difficulties, either subjectively or objectively.

2

Complains of forgetting location of objects; subjective word finding difficulties only.

3

Decreased job functioning evident to coworkers; difficulty in traveling to new locations.

4

Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances; marketing).

5

Requires assistance in choosing proper clothing for the season or occasion.

6a

Difficulty putting clothing on properly without assistance.

6b

Unable to bathe properly; may develop fear of bathing. Will usually require assistance adjusting bath water temperature.

6c

Inability to handle mechanics of toileting (i.e., forgets to flush; doesn't wipe properly).

6d

Urinary incontinence, occasional or more frequent.

6e

Fecal incontinence, occasional or more frequent.

7a

Ability to speak limited to about half a dozen words in an average day.

7b

Intelligible vocabulary limited to a single word in an average day.

7c

Nonambulatory (unable to walk without assistance).

7d

Unable to sit up independently.

7e

Unable to smile.

7f

Unable to hold head up.