a)

No difficulty speaking, hearing, reading and writing.

b)

Moderate impairment of communication. Accepts help.

c)

Severe impairments of communication faculties.

d)

Excessive difficulty in understanding or being understood.

Go to Question 2

a)

No difficulty recalling recent events, facts, directions, time, place, or person. Exercises good decision making.

b)

Occasional memory lapses but capable of participating in decision making with minor dependence on others.

c)

Memory loss and frequently disoriented. Often unable to make decisions without help.

d)

Severe memory loss and totally disoriented. Totally dependent upon others for decision making.

Go to Question 3

a)

Good morale and self worth, able to cope with and adapt to changes. Free from any mental symptoms that may hinder function.

b)

Occasional mood changes with symptoms such as anxiety, depression, phobias, or paranoia that are beginning to hinder function.

c)

More severe mood changes with symptoms that hinder function. May pose some health and safety risks.

d)

Serious mood changes. Symptoms such as anxiety, depression, phobias, or paranoia indicating possible danger to self or others.

Go to Question 4

a)

Normal, functional behavior patterns and moves with purposeful direction.

b)

Moves in aimless fashion in pursuit of indefinable or an unobtainable result, e.g., looking for visitors who are not coming.

c)

Disabling behaviors such as delusions or hallucinations that may cause emotional impairment.

d)

Behavior that indicates more severe emotional impairment. Extreme or erratic behavior patterns present. Inappropriate behavior, e.g., disrobing.

Go to Question 5

a)

Walks around unassisted.

b)

Walks with mechanical aides, needs more time and may need help occasionally.

c)

Walks with difficulty and requires coaxing and some supervision is needed.

d)

Unable to walk unassisted.

Go to Question 6

a)

Responsible for taking own medications correctly.

b)

Sometimes confused with medications and needs periodic supervision of dosage.

c)

Needs daily supervision of medications.

d)

Totally dependent upon others for proper medication regime.

Go to Question 7

a)

Uses only prescription drugs prescribed by physician. Minimal alcohol use.

b)

May use alternative drugs or alcohol along with prescription medications.

c)

Patterns of inappropriate use of drugs and/or alcohol but has not caused disturbances. Help accepted.

d)

Frequently uses drugs and/or alcohol inappropriately. Displays disruptive behavior. Refuses help.

Go to Question 8

a)

Prepares or obtains meals independently. Eats without assistance.

b)

Needs others to prepare meals or assist with meals on short-term basis. Eats without assistance.

c)

Requires more assistance with meal preparation and some assistance eating.

d)

Needs constant assistance with meal preparation and eating.

Go to Question 9

a)

Manages financial matters independently. Budgets, writes and cashes checks, pays bills.

b)

Manages some day-to-day purchases but needs help with banking, insurance, taxes. Accepts help.

c)

Difficulty handling all financial tasks and increasingly dependent. Accepts help.

d)

Incapable of handling financial matters. Refuses and denies needing help.

Go to Question 10

a)

Aware of and practices routine safety measures.

b)

Requires some teaching initially or reminders of safety measures.

c)

Does not regularly practice normal safety precautions and may be dangerous to self and others.

d)

Ignores or is unaware of safety practices which create a danger to self and others.

Go to Question 11

a)

Capable of doing own housekeeping.

b)

Performs light housekeeping tasks but cannot maintain acceptable level of cleanliness alone.

c)

Needs extensive regular help with all housekeeping.

d)

Does not participate in any housekeeping or refuses help in maintaining acceptable level of cleanliness.

Go to Question 12

a)

Maintains good interpersonal relationship with family and friends.

b)

Exhibits pattern of difficulties in maintaining relationships. Requires occasional counseling, encouragement and/or stimulation in dealing with these difficulties.

c)

Needs more counseling, encouragement and/or stimulation to maintain healthy relationships.

d)

Totally unaware of relationship issues. Not interested or concerned about others.

Go to Question 13

a)

Travels independently on public transportation, drives own car, or arranges own transportation.

b)

Travels on public vehicles with some help from others, arranges own transportation.

c)

Wants to go out but requires others to make transportation arrangements.

d)

Requires extensive supervision when going out. Often is resistant to going out.

Go to Question 14

a)

Needs no help with toileting

b)

Needs minimal help with toileting.

c)

Needs regular help with toileting and has occasional episodes of wetting or soiling.

d)

Soils or wets while awake, and is totally dependent on others for toileting.

Go to Question 15

a)

Bathes without help.

b)

Needs some supervision or needs minimal help to bathe.

c)

Needs regular assistance to bathe as well as frequent verbal cues.

d)

Cannot bathe and does not respond to repetitive verbal cues.

Go to Question 16

a)

Grooms self without help.

b)

Grooms self with minor help.

c)

Needs regular help or supervision to groom self.

d)

Unable to groom self and totally dependent upon others.

Go to Question 17

a)

Takes initiative and responsibility to dress unassisted.

b)

Needs minimal help, such as with buttons and tying. Responds to verbal cues.

c)

Needs more regular help. Does not always respond to repetitive cues to complete dressing. Needs substantial physical help with dressing functions.

d)

Unable to perform any tasks related to dressing.

Go to Question 18

a)

Obtains own groceries and other items needed.

b)

Obtains own groceries with some help from others.

c)

Cannot obtain food without regular help, yet expresses desire to do regular shopping.

d)

No interest in obtaining groceries and totally dependent upon others for food purchase.

Go to Question 19

a)

Does own laundry and cares for clothing alone.

b)

Needs minimal help yet is able to participate in major portion of laundry tasks.

c)

Unable to carry out all laundry functions. Needs some help.

d)

Does not do any of own laundry and is totally dependent upon others.

Go to Question 20

a)

Able to look up phone numbers, dial phone and converse understandably.

b)

Uses telephone with difficulty. May need electronic aid. Accepts help.

c)

Unable to use telephone yet maintains interest in using phone.

d)

Unable, unwilling and totally disinterested in using phone.