Study / Date Completed / Assessor / Subject ID / Study ID
M / M / D / D / Y / Y / Y / Y / # / # / # / # / # / # / # / # / # / # / # / # / # / # / # / #
Assessment: 1 Baseline
Now, I would like to ask you about some of the activities of daily living , things that we all need to do as a part of our daily lives. I would like to know if you can do these activities without ant help at all, or it you need some help to do them, or if you can’t do them at all.
(Be sure to read all answer choices if applicable in questions 1 through 7 to respondent)
Instrumental Activities of Daily Living
1. Can you use the telephone? iaphone
2 = Without help, including looking up numbers and dialing
1 = With some help (can answer phone or dial operator in an emergency, but need special phone or help in getting number or dialing)
0 = Are you completely unable to use the telephone?
2. Can you get to places out of walking distance iawalk
2 = Without help (can travel alone on buses, taxis, or drive your own car)
1 = With some help (need someone to help you or go with you when traveling)
0 = Are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?
3. Can you go shopping for groceries or clothes (ASSUMING S/HE HAS TRANSPORTATION iashop
2 = Without help (taking care of all shopping needs yourself, assuming you have transportation)
1 = With some help (need someone to go with you on all shopping trips)
0 = Are you completely unable to do any shopping?
4. Can you prepare your own meals? iameals
2 = Without help (plan and cook full meals yourself)
1 = With some help (can prepare some things but unable to cook full meals yourself)
0 = Are you completely unable to prepare meals
5. Can you do your housework iahswk
2 = Without help (can scrub floors, etc.)
1 = With some help (can do light housework but need help with heavy work)
0 = Are you completely unable to do any housework?
6. Can you take your own medicine iamed
2 = Without help (in the right doses at the right time)
1 = With some help (able to take medicine if someone prepares it for you and/ or reminds you to take it)
0 = Are you completely unable to take your medicine?
7. Can you handle your own money iamoney
2 = Without help (write checks, pay bills, etc.)
1 = With some help (manage day-to-day buying but need help with managing your checkbook and paying your bills)
0 = Are you completely unable to handle money?
InstrumentalActv/ Form Page 2 of 2 Primary Entered by: ______Date: ____/____/____
Version 1, 5/31/2006
Secondary Entered by: ______Date: ____/____/____