1. Bathing

Are you or your relative able to get in and out of the bath / shower, and wash?

Select oneDependentIndependent*
* Bath: must get in and out unsupervised and wash self. Shower: unsupervised/unaided.

2. Grooming

Are you or your relative able to wash themselves, comb hair, shave and clean teeth?

Select oneNeeds help with personal care: face, hair, teeth, shavingIndependent (implements provided)

3. Dressing

Are you or your relative able to put on all your / their clothes including fastening zips and buttons?

Select oneDependentNeeds help but can do about half unaidedIndependent (including buttons, zips, laces etc)

4. Feeding

If food is placed within easy reach are you or your relative able to cut up food / feed themselves?

Select oneUnableNeeds help in cutting, spreading butter etcIndependent (food provided within reach)

5. Mobility

How mobile are you or your relative?

Select oneImmobileWheelchair independent, including corners etcWalks with help of one person (verbal or physical)Independent

6. Transfer

How well do you or your relative sit and transfer to and from bed?

Select oneUnable - no sitting balanceMajor help (physical, one or two people); can sitMinor help (verbal or physical)Independent

7. Stairs

How well can you or your relative navigate the stairs?

Select oneUnableNeeds help (verbal, physical, carrying aid)Independent up and down

8. Continence (bowels)

Please state your level of contence

Select oneIncontinent (or needs to be given enema)Occasional accident (once a week)Continent

9. Continence (bladder)

Please state your level of contence

Select oneIncontinent, or catheterised and unable to manageOccasional accident (max. once per 24 hours)Continent (for more than 7 days)

10. Toilet use

How do you use the toilet?

Select oneDependentNeeds some help can do something aloneIndependent (on and off, wiping, dressing)