ADL

1

Name* This field is required.

First Name

Last Name

2

Date

3

How many hours spent on average at Home* This field is required.

4

How many hours spent on average going to doctor appointments, therapy, etc.* This field is required.

5

How many hours spent on average watching TV or other sedentary activies* This field is required.

6

How many hours spent on average doing physical exercise at home* This field is required.

7

How many hours spent on any other outdoor activities* This field is required.

9

Were you accompanied today* This field is required.

No

Yes

10

With whom* This field is required.

Family

Friend

Neighbor

Other

12

Can you travel alone?* This field is required.

Yes

No / Need Help

13

Can you drive alone?* This field is required.

Yes

No / Need Help

14

Can you get dressed alone?* This field is required.

Yes

No / Need Help

15

Can you go shopping alone?* This field is required.

Yes

No / Need Help

16

Can you schedule appointment(s) alone?* This field is required.

Yes

No / Need Help

17

Can you attend medical appointment(s) alone?* This field is required.

Yes

No / Need Help

18

Can you cook your meals alone?* This field is required.

Yes

No / Need Help

19

Can you bathe, shower, etc. alone?* This field is required.

Yes

No / Need Help

20

Can you do your daily housekeeping alone?* This field is required.

Yes

No / Need Help

21

Can you handle your finances alone?* This field is required.

Yes

No / Need Help

22

Can you take your medications alone?* This field is required.

Yes

No / Need Help

23

Can you use a cell/telephone by yourself?* This field is required.

Yes

No / Need Help