Pick one response in each of the following six areas. Give yourself the appropriate number of points for that response. Add up your points, and see what your total score tells you.

1. Mobility

A) Can walk unassisted from room to room and up and down stairs; could leave building without help in case of fire or other emergency...0 points

B) Uses a walker, wheelchair or cane; may occasionally need help getting to meals or the bathroom...8 points

C) Is confined to a bed or wheelchair; non-mobile...20 points

2. Eating/Medication

A) Needs no help shopping, cooking, eating or cleaning up after meals. Safely takes own medications at the correct time...0 points

B) Needs regular reminders to eat or needs help preparing meals. Needs some supervision to take medication safely; may tend towards confusion...10 points

C) Needs to be fed by someone, refuses to eat, or is nourished through a tube or IV line. Unable or unwilling to take own medications safely; is dependent on or abusing medications...20 points

3. Bathing/Dressing

A) Keeps clean, bathed and shampooed. Needs no help getting dressed, choosing appropriate clothes or keeping clothes clean and neat...0 points

B) Needs help getting in and out of bath or shower, needs help washing, or needs reminders about personal hygiene. Needs help with shoes, buttons or zippers...8 points

C) Is not able or willing to take care of personal hygiene. Does not dress self, or may take clothes off during the day...15 points

4. Memory and Safety/ Psychological Health

A) Memory problems, confusion, worry, sadness do not threaten personal safety or safety of others. Willing and able to attend to personal care, nutrition, medications without help...0 points

B) Has trouble managing personal care. Needs reminders that stove is on or water is running. May forget or need encouragement to eat, bathe or take medications...10 points

C) Assistance with personal care in the home or assisted living facility is no longer enough. May wander in neighborhood and get lost. Disorientation or behavior may threaten own or others'' safety...15 points

5. Hearing/Vision and Speech

A) Can hear normal-to-loud speech, use the phone in an emergency, respond to a fire alarm or other warning signal. Can read instructions and safety warnings; can use phone book or call out clearly in an emergency...0 points

B) Has trouble hearing warning alarms; unable or unwilling to use the telephone in emergencies. Can''t recognize faces more than a few feet away; can''t read instructions; has trouble speaking clearly...3 points

C) Is unable to understand what others are saying; cannot respond to safety alarm, or appears unwilling to communicate. Impaired vision or speech endangers personal safety; cannot call for help...10 points

6. Using the Bathroom

A) Needs no help using the toilet; controls incontinence, manages ostomy...0 points

B) May need occasional help getting to the toilet...5 points

C) Cannot control bladder or bowel function, soils or wets while awake or asleep; regularly uses bedpan or diapers...10 points

Add Your Score Here

(Total Score..............points)

0-17 points

Able

18-25 points

Needs

26-34 points

Requires

35 or more points

Needs