waterburychiropracticwellness.com - Activities of Daily Living

ACTIVITIES OF DAILY LIVING
Patient Name
Date

MonthDayYear
Date
Please mark all activities you experience trouble in performing or completing by yourself:

BakingBendingButtoning clothesBathingBending ArmDoing Things on TimeCare of OthersBending LegPlaying with grandchildrenCare of PetsCarrying objectsSensitivity to LightCaring of childrenClimbing stairsSitting to standingCleaningCrouching/SquattingStanding to sittingConcentratingGeneral MobilityUsing the computerCookingHead movement downUsing the phoneDoctor's officeHead movement upDressingHolding on to objectsDrivingKeeping balanceEatingLeaningFinancial ManagementLiftingGetting placesLying downHearingMoving joint(s)HouseworkPulling with feetLaundryPulling with handsMaking decisionsPushing with feetMowingPushing with handsPersonal hygiene/groomingReaching downSeeingReaching upSexual activityReaching outShoppingSittingSpeakingStandingWatching TVTurningWorkingTwistingYard WorkWalking
Exercising

EllipticalJoggingPilatesRow machineStair climberStretchingTreadmillWater aerobicsWeight liftingYoga
Hobbies

ColoringCrochetingDancingFishingGardeningKnittingPaintingPlaying musical instrumentPlaying pianoReadingSewingWoodworking
Sports

BaseballBasketballBike RidingBowlingCanoeingFootballGolfHikingHorseback RidingIce SkatingKayakingRacket Ball
List any other activity you have been able to do that you are no longer able to do:
Percentage of difficulty:

10%20%30%40%50%60%70%80%90%100%
Should be Empty:

ACTIVITIES OF DAILY LIVING