No. | Question | Scoring |
Response | Score | Response | Score | Response | Score | Response | Score |
1 | Do you need help to do the following? Bathing Bed mobility Medication management Transferring Ambulating Eating Toileting Dressing Personal hygiene | Zero to two selected | Zero | Three or more selected | Two | | | | |
2 | Do you need help turning and repositioning? | No | Zero | Yes | Two | | | | |
3 | Who helps you with daily activities? | No one | One | Fam-ily/friend/othe r/paid help | Zero | | | | |
4 | During the last six months, have you had a fall that caused injuries? | No | Zero | Yes | Two | | | | |
5 | Have you had a hospitalization, or been admitted to a nursing facility, or both, in the past six months? | No | Zero | Yes | Two | | | | |
6 | Have you received rehabilitation in the past six months? | No | Zero | Yes | Two | | | | |
7 | Have you been treated in an emergency room, called 911 in the past six months, or both? | No | Zero | Yes, one to two times | One | Yes, three or more times | Two | | |
8 | Do you live alone? If yes, do you feel safe living alone? | No No | Zero One | Yes Yes | Two Zero | | | | |
9 | Do you plan on moving to other housing in the near future? | No | Zero | Yes | Two | | | | |
10 | Do you or your family have concerns about your memory, thinking, ability to make decisions, or remembering to pay your bills? | No, not concerned | Zero | Yes, somewhat concerned | One | Yes, very concerned | Two | | |
11 | Are you content with your social life? | No | Two | Somewhat | One | Yes | Zero | | |
12 | Over the last two weeks, have you been bothered by, or have little interest in doing things? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |
13 | Over the last two weeks, have you been bothered by feeling down, depressed, or hopeless? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |