Patient Initials: Date:
Katz Index of Independence in Activities of Daily Living
Points (1 or 0)
NO supervision, direction or personal assistance.
WITH supervision, direction, personal assistance or total care.
|(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity.||(0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing|
|(1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.||(0 POINTS) Needs help with dressing self or needs to be completely dressed.|
|(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.||(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.|
|(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable||(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.|
|(1 POINT) Exercises complete self control over urination and defecation.||(0 POINTS) Is partially or totally incontinent of bowel or bladder|
|(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.||(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.|
TOTAL POINTS: SCORING: 6 = High (patient independent) 0 = Low (patient very dependent
· Patient is:
Geriatric Depression Scale (Short Form):
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home rather than go out and do new things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you are?
SCORE: __/15. Assessment: _______________