EL – IADL

(Lawton) Instrumental Activities of Daily Living

Patient: [textarea cols=40 rows=1]
Sex: [checkbox name="sex" value="male|female"]
DOB: [textarea cols=12 rows=1]
Age: [textarea cols=12 rows=1]

(Lawton) Instrumental Activities of Daily Living

Using telephone: [select name="Q1" value="Without help =3|With some help =2|Completely unable =1"]

Using transportation: [select name="Q2" value="Without help =3|With some help =2|Completely unable =1"]

Shopping: [select name="Q3" value="Without help =3|With some help =2|Completely unable =1"]

Preparing meals: [select name="Q4" value="Without help =3|With some help =2|Completely unable =1"]

Housework: [select name="Q5" value="Without help =3|With some help =2|Completely unable =1"]

Doing repairs: [select name="Q6" value="Without help =3|With some help =2|Completely unable =1"]

Doing laundry: [select name="Q7" value="Without help =3|With some help =2|Completely unable =1"]

Handling medication: [select name="Q8" value="Without help =3|With some help =2|Completely unable =1"]

Handling finances: [select name="Q9" value="Without help =3|With some help =2|Completely unable =1"]

Score: [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8)+(Q9)" memo="score"]
(Lawton) Instrumental Activities of Daily Living

Patient:

Sex:
DOB:

Age:


(Lawton) Instrumental Activities of Daily Living

Using telephone:

Using transportation:

Shopping:

Preparing meals:

Housework:

Doing repairs:

Doing laundry:

Handling medication:

Handling finances:

Score: scorescore=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)+(Q7)+(Q8)+(Q9)

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.77, 14 form elements, 33 boilerplate words, 3 text areas, 1 checkboxes, 9 drop downs, 1 calculations, 14 total clicks
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