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Pre-visit questionnaire: Daily activities

Pre-visit questionnaire: Daily activities
Task No help needed Help needed Who helps?
Feeding yourself      
Getting from bed to chair      
Getting to the toilet      
Getting dressed      
Bathing or showering      
Walking across the room (includes using cane or walker)      
Using the telephone      
Taking your medicines      
Preparing meals      
Managing money (like keeping track of expenses or paying bills)      
Moderately strenuous housework such as doing the laundry      
Shopping for personal items like toiletries or medicines      
Shopping for groceries      
Driving      
Climbing a flight of stairs      
Getting to places beyond walking distance (eg, by bus, taxi, or car)      
Reproduced with permission from: Division of Geriatric Medicine. UCLA Healthcare. Pre-Visit Questionnaire. Copyright © 2013 The Regents of the University of California.
Graphic 89012 Version 1.0

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