ACTIVITIES OF DAILY LIVING
Patient Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please mark all activities you experience trouble in performing or completing by yourself:
Baking
Bending
Buttoning clothes
Bathing
Bending Arm
Doing Things on Time
Care of Others
Bending Leg
Playing with grandchildren
Care of Pets
Carrying objects
Sensitivity to Light
Caring of children
Climbing stairs
Sitting to standing
Cleaning
Crouching/Squatting
Standing to sitting
Concentrating
General Mobility
Using the computer
Cooking
Head movement down
Using the phone
Doctor's office
Head movement up
Dressing
Holding on to objects
Driving
Keeping balance
Eating
Leaning
Financial Management
Lifting
Getting places
Lying down
Hearing
Moving joint(s)
Housework
Pulling with feet
Laundry
Pulling with hands
Making decisions
Pushing with feet
Mowing
Pushing with hands
Personal hygiene/grooming
Reaching down
Seeing
Reaching up
Sexual activity
Reaching out
Shopping
Sitting
Speaking
Standing
Watching TV
Turning
Working
Twisting
Yard Work
Walking
Exercising
Elliptical
Jogging
Pilates
Row machine
Stair climber
Stretching
Treadmill
Water aerobics
Weight lifting
Yoga
Hobbies
Coloring
Crocheting
Dancing
Fishing
Gardening
Knitting
Painting
Playing musical instrument
Playing piano
Reading
Sewing
Woodworking
Sports
Baseball
Basketball
Bike Riding
Bowling
Canoeing
Football
Golf
Hiking
Horseback Riding
Ice Skating
Kayaking
Racket 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%
Submit
Should be Empty: