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PLEASE ANSWER THE QUESTIONS BELOW IN REGARDS TO TODAY'S VISIT.
Dress yourself, including shoelaces and buttons? Shampoo your hair? YesWith some difficultNo
Shampoo your hair? YesWith some difficultNo
Stand up from a chair? YesWith some difficultNo
Get in and out of bed? YesWith some difficultNo
Cut your own meat? YesWith some difficultNo
Lift a full cup or glass to your mouth? YesWith some difficultNo
Open a new milk carton? YesWith some difficultNo
Devices used for DressingSpecial or built up chairBuilt up or special utensilsCaneWalkerCrutchesWheelchairCPNP
Raised toilet seatBathtub seatBathtub barAppliances in bathroomLong-handled appliancesJar opener
EatRestroomHygieneReachGripping and Opening thingsGymErrands and choresDrivingPlay Dominoes,Play CardsFishingListening Music
Make bed/Get DressedEat/Brush TeethReligion/Spiritual ReadingMathReadingWriting/Handwriting PracticeGrammarSpellingScience/HealthHistory/GeographyPhysical Education/SportsArtsMusicForeign LanguagePerforming ArtsComputer SkillsChess/Strategy GamesChoresPick up things before bedPajamas/Brush Teet /Drink