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Geriatric Assessment Tool
Instrumental Activities of Daily Living
Client Name
|
Assessment Date
|
________________________________________ |
_______________ |
Please check the box that most applies for each activity:
| Activity |
Need No Help
(2 pts. each) |
Need Some Help
(1 pt. each) |
Unable to Do At All
(0 pts.
each) |
| 1. Using the Telephone |
___ |
___ |
___ |
| 2. Getting to Places Beyond Walking Distance |
___ |
___ |
___ |
| 3. Grocery Shopping |
___ |
___ |
___ |
| 4. Preparing Meals |
___ |
___ |
___ |
| 5. Doing Housework or Handyman Work |
___ |
___ |
___ |
| 6. Doing Laundry |
___ |
___ |
___ |
| 7. Taking Medications |
___ |
___ |
___ |
| 8. Managing Money |
___ |
___ |
___ |
| Total Score: ___ = |
(___ x 2 =) ___ + |
(___ x 1=) ___ + |
0 |
Assessed By
|
Signature
|
________________________________ |
________________________________ |
References
From Lawton, M.P., and Brody, E.M. (1969). Assessment of older people:
Self-maintaining and instrumental activities of daily living. The
Gerontologist, 9, 179-186. Copyright (c) by The Gerontological Society
of America. |
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Stall Geriatrics LLC, 350 Greenhaven Terrace, Tonawanda, NY 14150 W 716-213-4345 F 888-387-1238 E-mail drstall@stallgeriatrics.com
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Last update 4/20/11
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