1. Bend to your feet to put on your underwear and pants on your own |
2. Bend to your feet to put on your socks and shoes on your own |
3. Bend forward to pick up a small object on the floor on your own |
4. Bend forward to wash your face and hair without getting wet |
5. Bathe the lower half of your body on your own |
6. Perform personal hygiene functions following toileting |
7. Bend forward to clean the floor on your own |
8. Sit down on the chair and get up on your own |
9. Lie down on the bed and get up on your own |
10. Get in and out of a car on your own |
11. Take a small object sideways on your own |
Response options and score for each item |
0 No effect at all |
1 Help oneself but have minor effect |
2 Help oneself but have effect |
3 Help oneself but have significant effect |
4 Cannot help oneself require assistance |
5 Cannot do at all |