Activities of Daily Living

Toilet: [select name="Q1" value="Care for self at toilet completely; no incontinence =4|Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents =3|Soiling or wetting while asleep more than once a week =2|Soiling or wetting while awake more than once a week =1|No control of bowels or bladder =0"]

Feeding: [select name="Q2" value="Eats without assistance =4|Eats with minor assistance at meal times and/or with special preparation of food, or help in cleaning up after meals =3|Feeds self with moderate assistance and is untidy =2|Requires extensive assistance for all meals =1|Does not feed self at all and resists efforts of others to feed him or her =0"]

Dressing: [select name="Q3" value="Dresses, undresses, and selects clothes from own wardrobe =4|Dresses and undresses self with minor assistance =3|Needs moderate assistance in dressing and selection of clothes =2|Needs major assistance in dressing but cooperates with efforts of others to help =1|Completely unable to dress self and resists efforts of others to help =0"]

Grooming: [select name="Q4" value="Always neatly dressed and well-groomed without assistance =4|Grooms self adequately with occasional minor assistance, eg, with shaving =3|Needs moderate and regular assistance or supervision with grooming =2|Needs total grooming care but can remain well-groomed after help from others =1|Actively negates all efforts of others to maintain grooming =0"]

Ambulation: [select name="Q5" value="Goes about grounds or city =7|Ambulates within residence on or about one block distant =6|Ambulates with assistance of another person =5|Ambulates with assistance of cane =4|Ambulates with assistance of walker =3|Ambulates with assistance of wheelchair, gets in and out without help =2|Ambulates with assistance of wheelchair, needs help getting in and out =1|Bedridden more than half the time =0"]

Bathing: [select name="Q6" value="Bathes self (tub, shower, sponge bath) without help =4|Bathes self with help getting in and out of tub =3|Washes face and hands only but cannot bathe rest of body =2|Does not wash self but is cooperative with those who bathe him or her =1|Does not try to wash self and resists efforts to keep him or her clean =0"]

Score: [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)" memo="score"]
Activities of Daily Living







Score: scorescore=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 1, 7 form elements, 11 boilerplate words, 6 drop downs, 1 calculations, 6 total clicks
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