DLA-20

DLA-20
Daily Living Activities (DLA-20): Adult Mental Health
Date*

MonthDayYear
Date
Person completing DLA-20:*

First NameLast Name
Title:*
Client Name:*

First NameLast Name
DLA20 Training Date:*

MonthDayYear
Date
DLA20 Training Instructor:*

First NameLast Name
Instructions: Using the scale below, rate how often or how well the consumer independently performed or managed each of the 20 Activities of Daily Living (ADLs) in the community during the last 30 days.

If the consumer's level of functioning varied, rate the lower score. Consider Impairments in functioning due to physical limitations as well as those due to mental impairments. Do not consider environmental limitations (e.g., "no jobs available").

Strengths are score >=5 in an activity and indicate functioning "within normal limits" (WNL) for that activity.

Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
Scoring Matrix:
1. HEALTH PRACTICES: Takes care of health issues, manages moods, infections; takes medication as prescribed; follows up on medical appointments

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
2. HOUSE STABILITY, MAINTENANCE: Maintains stable housing; organizes possessions, cleans, abides by rules and contributes to maintenance if living with others

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
3. COMMUNICATION: Listens to people, expresses opinions/feelings; makes wishes known effectively

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
4. SAFETY: Safely moves about community - adequate vision, hearing, makes safe decisions. Safely uses small appliances, ovens/burners, matches, knives, razors, other tools

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
5. MANAGING TIME: Follows regular schedule for bedtime, wake-up, meal times, rarely tardy or absent for work, day programs, appointments, scheduled activities.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
6. MANAGING MONEY: Manages money wisely (independent source of funds); controls spending habits.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
7. NUTRITION: Eat at least 2 basically nutritious meals daily

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
8. PROBLEM SOLVING: Resolves basic problems of daily living, asks questions for clarity and setting expectations.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
9. FAMILY RELATIONSHIP: Gets along with family, positive relationships as parent, sibling, child, significant other family member.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
10. ALCOHOL/DRUG USE: Avoids abuse or abstains from alcohol/drugs, cigarettes; understands signs and symptoms of abuse or dependency; avoids misuse or combining alcohol, drugs medication.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
11. LEISURE: Relaxes with a variety of activities; attends/participates in sports or performing arts events; reads newspapers, magazines, books; recreational games with others; involved arts/crafts; goes to movies.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
12. COMMUNITY RESOURCES: Uses other community services, self-help groups, telephone, public transportation, religious organizations, shopping.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
13. SOCIAL NETWORK: Gets along with friends, neighbors, coworkers, other peers.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
14. SEXUALITY: Appropriate behavior toward others; comfortable with gender, respects privacy and rights of others, practices safe sex or abstains.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
15. PRODUCTIVITY: Independently working, volunteering, homemaking, or learning skills or self-support.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
16. COPING SKILLS: Knows about nature of disability/illness, probable limitations and symptoms of relapse; behaviors that cause relapse or make situation/condition worse; makes plans and uses options for coping, improving preventing relapse, restoring feelings of self-worth, competence, being in control.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
17. BEHAVIOR NORMS: Complies with Community norms, probation/parole, court requirements, if applicable; controls dangerous, violent, aggressive, bizarre, or nuisance behaviors; respects rights of others.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
18. PERSONAL HYGIENE: Cares for personal cleanliness, such as bathing, brushing teeth.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
19. GROOMING: Cares for hair, hands, general appearance; shaves.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
20. DRESS: Dresses self; wears clean clothes that are appropriate for weather, job, and other activities; clothing is generally neat and intact.

1

2

3

4

5

6

7

1 is Extremely Severe, 7 is Independent ALL THE TIME
Enter N/A only if the activity was not assessed & do no exceed 5 N/A DLAs.
Should be Empty:

DLA-20

Daily Living Activities (DLA-20): Adult Mental Health

Scoring Matrix: