II. Survey
- Based on 6 criteria (1 point each if independent, 0 points if dependent)
- Bathing with sponge, bath, or shower
- Dependent if needs help with bathing more than one body part, or in getting in or out of bath or shower
- Dressing
- Dependent if needs help dressing self or needs to be completely dressed
- Toilet Use
- Dependent if needs help Transferring self to toilet, cleaning self or uses bedpan or commode
- Transferring (in and out of bed or chair)
- Dependent if needs help moving from bed to chair or needs complete assistance
- Urine and Bowel Continence
- Dependent if partially or totally incontinent of bowel or Bladder
- Eating
- Dependent if needs partial or complete help with feeding or needs Parenteral feeding
- Bathing with sponge, bath, or shower
- Each criteria is graded on level of dependence
- Performs independently (1 point assigned) OR
- Performs only with assistance
III. Interpretation
- Level of ADL Dependence graded via score
- Dependence in ADLs suggested by score of 0 to 1
- Independent in ADLs increases as score approaches 6