Daily Function Assessment

Mark an X in the space that best describes how you do the following activities.
Activity	I do it myself	Need some help	Someone else does it for me
Cook	___	___	___
Do housework	___	___	___
Do laundry	___	___	___
Manage money	___	___	___
Shop for groceries	___	___	___
Take medication	___	___	___
Use the telephone	___	___	___

Mark an X in the space that best describes the trouble you have doing these tasks.
Activity	No difficulty	Some difficulty	A lot of difficulty
Bathe	___	___	___
Dress	___	___	___
Eat	___	___	___
Get in and out of bed	___	___	___
Get in and out of a chair	___	___	___
Go to the bathroom	___	___	___
Walk without a cane or walker	___	___	___

Copyright 2004. Robert S. Stall, MD / Stall Geriatrics. All Rights Reserved.