Thank You Contacting Our Service. You Said You Have Difficulty with One Or More of Your

Our Ref:

Thank you contacting our service. You said you have difficulty with one or more of your daily living activities?

Our offer of support to you will be determined by what you tell us, what abilities you have, and the support that you presently receive.

Each person’s ability to cope with their daily activities differs and by looking at all your daily activities we can get a picture of your overall ability to cope.

In order to find out what you can do and what you are finding difficult please complete the enclosed self -assessment questionnaire.

The questionnaire asks you to provide answers to everything that you do in your daily life (and not just the areas that you have asked for help with).

If you send us the completed form we may arrange a visit with you to discuss and assess your specific support needs further.

Thank you

EXTENDED DAILY LIVING ACTIVITIES QUESTIONNAIRE

(This questionnaire is to find out what you have been doing in the past week)

PLEASE TICK ONLY ONE BOX FOR EACH QUESTION

Please record only WHAT YOU HAVE ACTUALLY DONE IN THE LAST WEEK OR SO (NOT what you think you could do, ought to do or would like to do).

If you are unable to fill it in yourself, please get a relative or friend to fill it in for you.

Once completed the questionnaire allows you to add up your score: please add up your score

Mobility No With On my On my

help own with own

difficulty

1. Did you walk around outside? [ ] [ ] [ ] [ ]

2. Did you climb stairs? [ ] [ ] [ ] [ ]

3. Did you get in and out of the car? [ ] [ ] [ ] [ ]

4. Did you walk over uneven ground? [ ] [ ] [ ] [ ]

5. Did you cross roads? [ ] [ ] [ ] [ ]

6. Did you travel on public transport? [ ] [ ] [ ] [ ]

Kitchen No With On my On my

help own with own

difficulty

1. Did you feed yourself? [ ] [ ] [ ] [ ]

2. Did you make yourself [ ] [ ] [ ] [ ]

a hot drink?

3. Did you carry hot drinks from one

room to another? [ ] [ ] [ ] [ ]

4. Did you do the washing up? [ ] [ ] [ ] [ ]

5. Did you make yourself a hot snack? [ ] [ ] [ ] [ ]

Domestic No With On my On my

help own with own

difficulty

1. Did you manage your own money

when you were out? [ ] [ ] [ ] [ ]

2. Did you wash small items of clothing,

like socks? [ ] [ ] [ ] [ ]

3. Did you do your own housework? [ ] [ ] [ ] [ ]

4. Did you do your own shopping? [ ] [ ] [ ] [ ]

5. Did you do a full clothes wash? [ ] [ ] [ ] [ ]

Leisure No With On my On my

help own with own

difficulty

1. Did you read newspapers or books? [ ] [ ] [ ] [ ]

2. Did you use the telephone? [ ] [ ] [ ] [ ]

3. Did you write letters? [ ] [ ] [ ] [ ]

4. Did you go out with friends? [ ] [ ] [ ] [ ]

5. Did you manage your garden? [ ] [ ] [ ] [ ]

6. Did you drive a car? [ ] [ ] [ ] [ ]

Personal Hygiene No With On my On my

help own with own

difficulty

1. Did you wash your own body? [ ] [ ] [ ] [ ]

2. Did you shave yourself? [ ] [ ] [ ] [ ]

3. Did you wash your own hair? [ ] [ ] [ ] [ ]

4. Did you brush your own hair? [ ] [ ] [ ] [ ]

5. Did you clean your own teeth? [ ] [ ] [ ] [ ]

6. Did you manage your own sanitary [ ] [ ] [ ] [ ]

needs?

7. Did you clean yourself after you

have been to the toilet? [ ] [ ] [ ] [

Bathing Transfer

Please tick which you have in your home:

a) Bath [ ]

b) Over Bath Shower [ ]

c) Shower Tray/ Wet Room [ ]

No With On my On my

help own with own

difficulty

1. Did you have a bath/shower? [ ] [ ] [ ] [ ]

Dressing

1. Did you dress yourself? [ ] [ ] [ ] [ ]

2. Did you put on your own socks,

tights, trousers or skirt? [ ] [ ] [ ] [ ]

3. Did you put on your own vest, bra,

shirt, blouse, jumper? [ ] [ ] [ ] [ ]

Bed Transfers

1. Did you get into bed by yourself? [ ] [ ] [ ] [ ]

Chair Transfers

1. Did you sit down and get up from

a chair? [ ] [ ] [ ] [

Please add up your score: this will tell you what to do next

Scoring:

Tick “No” or “With help” = 1

Tick “On my own with difficulty” or “On my own” = 0

Your score:

14 or more: means you have reversible or long term support needs.

Below 14: means your needs can be met through local community services. For information on these services see attached sheet (local suppliers / retailers).

However if you have any concerns regarding the scoring or need help to interpret your score please send your questionnaire to:

If you score 14 or more please return completed questionnaire plus attached covering letter to:

Core Rehabilitation Team

Cromwell Primary Care Centre

Cromwell Road

Grimsby

DN31 2BH

Please ensure that correct postage is added

Alternatively a completed form can be returned via e mail to

Thank you

Cover Letter: please add your details below & return with completed questionnaire to Core Rehabilitation Team

NHS NUMBER:

Date of Birth:

Your name:

Your address:

Tell us about the specific difficulties you are having:

What equipment or techniques have you already tried?

Equipment:

Techniques:

Local Suppliers/ Retailers

Eden Mobility TEL 01472 800180

G5, Flottergate Mall

Freshney Place Shopping Centre

Grimsby DN31 1QX

Portland Healthcare TEL 01472 353838

Weelsby View Medical Centre

Ladysmith Road

Grimsby DN32 9EF

The Scooter Centre TEL 01472 600055

11 High Street

Cleethorpes DN35 8LA

The Scooter Brokers

Garibaldi House

Grimsby DN32 7DU

Boothferry Mobility

176 Freeman Street

Grimsby DN32 7AT

Martin Robinson

Rightcare Mobility

25-27 Grimsby Road

Cleethorpes

DN35 7AQ

01472 354543

Age UK Stair lifts 0800 00198625 Bathing equipment 0800 9759838

Red Cross (Equipment Hire) Tel 01472 753638

Home Improvement Team (Advice regarding self finance of adaptations via loans). Tel 01472 324777

Able 4 U (handy man services) 01472 268890/ 730303

The Carers’ Support Service (Advice and support for carers) The Old Waterworks Offices 1 Town Hall Square Grimsby DN31 1HY 01472 242277