Check highest consecutive level of disability
1. No difficulty either subjectively or objectively.
2. Complains of forgetting location of objects. Subjective work difficulties.
3. Decreased job functioning evident to co-workers. Difficulty in traveling to new locations. Decreased organizational capacity.*
4. Decreased ability to perform complex tasks, e.g., planning dinner for guests, handling personal finances (such as forgetting to pay bills), difficulty marketing, etc.
5. Requires assistance in choosing proper clothing to wear for the day, season or occasion, e.g., patient may wear the same clothing repeatedly, unless supervised.*
- A. Improperly putting on clothes without assistance or cuing (e.g., may put street clothes on over night clothes, or put shoes on wrong feet, or have difficulty buttoning clothing) occasionally or more frequently over the past weeks.
- B. Unable to bathe properly (e.g., difficulty adjusting bath-water temperature) occasionally or more frequently over the past weeks.*
- C. Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly or properly dispose of toilet tissue) occasionally or more frequently over the past weeks.*
- D. Urinary incontinence (occasionally or more frequently over the past weeks).*
- E. Fecal incontinence (occasionally or more frequently over the past weeks).*
- A. Ability to speak limited to approximately a half a dozen intelligible different words or fewer, in the course of an average day or in the course of an intensive interview.
- B. Speech ability is limited to the use of a single intelligible word in an average day or in the course of an intensive interview (the person may repeat the word over and over).
- C. Ambulatory ability is lost (cannot walk without personal assistance).
- D. Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair).
- E. Loss of ability to smile.
- F. Loss of ability to hold up head independently.
* Score primarily on the basis of information obtained from knowledgeable informant and/or category.
Adapted from U.S. Department of Health and Human Services. Important questions for hospice in the next century. Internet. Accessed on January 25, 2016.