Version May 2024
| Activities | Independence | Dependence |
| Points (1 or 0) | Points (1) NO supervision, direction, or personal assistance | Points (0) WITH supervision, direction, personal assistance, or total care |
| Bathing | (1 point) Bathes self completely or needs help in bathing only a single part of the body, such as the back, genital area, or disabled extremity. | (0 points) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing. |
| POINTS:_____ | ||
| Dressing | (1 point) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes. | (0 points) Needs help with dressing self or needs to be completely dressed. |
| POINTS:_____ | ||
| Toileting | (1 point) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help. | (0 points) Needs help transferring to the toilet and cleaning self or uses bedpan or commode. |
| POINTS:_____ | ||
| Transferring | (1 point) Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable. | (0 points) Needs help in moving from bed to chair or requires a complete transfer. |
| POINTS:_____ | ||
| Continence | (1 point) Exercises complete self-control over urination and defecation. | (0 points) Is partially or totally incontinent of bowel or bladder. |
| POINTS:_____ | ||
| Feeding | (1 point) Gets food from plate into mouth without help. Preparation of food may be done by another person. | (0 points) Needs partial or total help with feeding or requires parenteral feeding. |
| POINTS:_____ | ||
| Total points:_____ | ||
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