1 | Able to do the activity without difficulty |
2 | Able to do the activity with little effort |
3 | Able to do the activity with a lot of effort |
4 | Cannot do the activity by yourself |
| |
How well are you able to.......... |
1 | Cut food with a knife and fork | 1 | 2 | 3 | 4 |
2 | Use a spoon to drink soup | 1 | 2 | 3 | 4 |
3 | Hold a cup of tea | 1 | 2 | 3 | 4 |
4 | Pour milk from a cup or carton | 1 | 2 | 3 | 4 |
5 | Wash and dry dishes | 1 | 2 | 3 | 4 |
6 | Brush your teeth | 1 | 2 | 3 | 4 |
7 | Use a handkerchief to blow your nose | 1 | 2 | 3 | 4 |
8 | Have a bath | 1 | 2 | 3 | 4 |
9 | Use the lavatory | 1 | 2 | 3 | 4 |
10 | Wash your face and hands | 1 | 2 | 3 | 4 |
11 | Tie up your shoe laces | 1 | 2 | 3 | 4 |
12 | Do up buttons | 1 | 2 | 3 | 4 |
13 | Do up a zip | 1 | 2 | 3 | 4 |
14 | Write a letter | 1 | 2 | 3 | 4 |
15 | Put a letter in an envelope | 1 | 2 | 3 | 4 |
16 | Hold and read a newspaper | 1 | 2 | 3 | 4 |
17 | Dial a telephone | 1 | 2 | 3 | 4 |
18 | Make yourself understood on the phone | 1 | 2 | 3 | 4 |
19 | Watch the television | 1 | 2 | 3 | 4 |
20. | Pick up your change in a shop | 1 | 2 | 3 | 4 |
21 | Insert an electric plug into a socket | 1 | 2 | 3 | 4 |
22 | Unlock your front door with the key | 1 | 2 | 3 | 4 |
23 | Walk up and down the stairs | 1 | 2 | 3 | 4 |
24 | Get up out of an armchair | 1 | 2 | 3 | 4 |
25 | Carry a full shopping bag | 1 | 2 | 3 | 4 |