Medical Questionnaire – Level of autonomy assessment (ADL/IADL) Last Name(Required) First Name(Required) Date of Birth(Required) DD dash MM dash YYYY Please check the best answer for each item described below concerning certain activities of daily living and domestic life.Sedentary Habits (sitting to watch TV, talking on the phone, reading, working on the computer, etc.) Most of the day Half of the day A small part of the day Rarely Activities of Daily Living (dressing, bathing, etc.) Need assistance Quite difficult A little difficult No problem Doing Laundry Unable Occasionally Regularly, one step at a time or with assistance Regularly and without assistance Cooking Unable Meals taken as fast food (take-out), simple meals only, or breakfast only Meals cooked in a Crockpot or frozen then reheated in the oven or microwave Regular meals Housekeeping Unable Light dusting, rearranging objects Regular housekeeping, one step at a time or with assistance No restrictions Grocery Shopping Unable Occasionally (1 or 2 times a month) Frequently, but with assistance No problem Attending Social Activities (church, family or friends' outings, etc.) Unable Rarely Occasionally (1 or 2 times a month) Frequently (every week or more) Driving Unable Very limited Cautious, local outings No restriction (long trips, through traffic) Running Errands (shopping, post office, dropping off a child at daycare, etc.) No errands possible 0-1 per day 2-3 per day Few or no restrictions CAPTCHA
