Patient Initials:
Date:
|
Katz Index of Independence in Activities of Daily Living |
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|
Activities
Points (1 or 0) |
Independence
(1 Point)
NO supervision, direction or personal assistance. |
Dependence
(0 Points)
WITH supervision, direction, personal assistance or total care. |
|
BATHING
Points: |
(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 |
|
DRESSING
Points: |
(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. |
|
TOILETING
Points: |
(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. |
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TRANSFERRING
Points: |
(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. |
|
CONTINENCE
Points: |
(1 POINT) Exercises complete self control over urination and defecation. | (0 POINTS) Is partially or totally incontinent of bowel or bladder |
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FEEDING
Points: |
(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. |
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TOTAL POINTS: SCORING: 6 = High (patient independent) 0 = Low (patient very dependent |
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- Patient is:
Geriatric Depression Scale (Short Form):
- Are you basically satisfied with your life?
- Have you dropped many of your activities and interests?
- Do you feel that your life is empty?
- Do you often get bored?
- Are you in good spirits most of the time?
- Are you afraid that something bad is going to happen to you?
- Do you feel happy most of the time?
- Do you often feel helpless?
- Do you prefer to stay at home rather than go out and do new things?
- Do you feel you have more problems with memory than most?
- Do you think it is wonderful to be alive now?
- Do you feel pretty worthless the way you are now?
- Do you feel full of energy?
- Do you feel that your situation is hopeless?
- Do you think that most people are better off than you are?
SCORE: __/15. Assessment: _______________
