Activities of daily living

Full Name *

For each item circle the number which describes how easy or difficult it is for you to perform the activity.

1. Cut food with a knife and fork *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

2. Use a spoon to drink soup *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

3. Hold a cup of tea *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

4. Pour milk from a bottle or carton *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

5. Wash and dry dishes *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

6. Brush your teeth *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

7. Use a handkerchief to blow your nose *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

8. Use a bath *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

9. Use a lavatory *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

10. Wash your face and hands *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

11. Tie up your shoelaces *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

12. Do up buttons *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

13. Do up a zipper *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

14. Write a letter *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

15. Put a letter in an envelope *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

16. Hold and read a newspaper *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

17. Dial a telephone *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

18. Make yourself understood on the telephone *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

19. Watch television *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

20. Pick up your change in a shop *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

21. Insert an electric plug into a socket *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

22. Unlock your front door with the key *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

23. Walk up and down stairs *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

24. Get up out of an armchair *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)

25. Carry a full shopping bag *

Able to do the activity without difficulty (1)

Able to do the activity with a little effort (2)

Able to do the activity with a lot of effort (3)

Cannot do the activity by yourself (4)