Has the participant had a definite or probable myocardial infarction?
No
Yes

Has the participant been hospitalized or treated for congestive heart failure?
No
Yes

Does the participant have peripheral vascular disease?
(Note: this includes the following: intermittent claudication or past bypass for chronic arterial insufficiency; previous gangrene or acute arterial insufficiency; or untreated thoracic or abdominal aneurysm which is ≥6 cm)
No
Yes

Has the participant had a cerebrovascular accident with minor or no residua, or a transient ischemic attack?
No
Yes

Does the participant have dementia or chronic cognitive deficit?
No
Yes

Has the participant had chronic pulmonary disease?
No
Yes

Has the participant had connective tissue disease?
No
Yes

Has the participant had peptic ulcer disease?
No
Yes

Does the participant have liver disease?
(Note: Severe, moderate, and mild liver disease are defined as follows: severe signifies cirrhosis and portal hypertension with past variceal bleeding; moderate signifies cirrhosis and portal hypertension but no past variceal bleeding; mild signifies chronic hepatitis or cirrhosis without portal hypertension.)
No
Yes, mild
Yes, moderate to severe

Does the participant have diabetes mellitus?
(Note: End-organ damage includes retinopathy, neuropathy, nephropathy, or brittle diabetes.)
None or diet-controlled
Yes, uncomplicated
Yes, with end-organ damage

Has the participant had hemiplegia?
No
Yes

Does the participant have moderate to severe chronic kidney disease?
(Note: Severe signifies on dialysis, a past kidney transplant, or uremia; moderate signifies serum creatinine >3 mg/dL.)
No
Yes

Does the participant have a solid tumor?
No (or localized and over 5 years ago)
Yes, localized and within the past 5 years
Yes, metastatic

Does the participant have leukemia (acute or chronic)?
No
Yes

Does the participant have lymphoma?
No
Yes

Does the participant have AIDS?
No
Yes

Bathing (tub bath, shower, or sponge bath)
Independent
Dependent

Dressing (includes both taking clothes from the wardrobe/drawers/etc. and getting dressed)
Independent
Dependent

Toileting (going to the toilet room, using toilet, arranging clothes; please select “Dependent” if participant uses a bedpan or commode)
Independent
Dependent

Transference (in and out of a bed, on or off of a chair, etc.)
Independent
Dependent

Continence (self-control over urination and defecation)
Independent
Dependent

Feeding
Independent
Dependent

Ability to use telephone
Operates telephone on own initiative; looks up and dials numbers
Dials a few well-known numbers
Answers telephone but does not dial
Does not use telephone at all

Shopping
Takes care of all shopping needs independently
Shops independently for small purposes
Needs to be accompanied on any shopping trip
Completely unable to shop

Food preparation
Plans, prepares, and serves adequate meals independently
Prepares adequate meals if supplied with ingredients
Heats and serves prepared meals or prepares meals but does not maintain adequate diet
Needs to have meals prepared and served

Housekeeping
Maintains house alone with occasional assistance for heavy work
Performs light daily tasks such as dishwashing, bed making
Performs light daily tasks, but cannot maintain acceptable level of cleanliness
Needs help with all home maintenance tasks
Does not participate in any housekeeping tasks

Laundry
Does personal laundry completely
Launders small items, rinses socks, stockings, etc.
All laundry must be done by others

Mode of Transportation
Travels independently on public transportation or drives own car
Arranges own travel via taxi, but does not otherwise use public transportation
Travels on public transportation when assisted or accompanied by another
Travel limited to taxi or automobile with assistance of another
Does not travel at all

Responsibility for Own Medication
Is responsible for taking medication in correct dosages at correct time
Takes responsibility if medication is prepared in advance in separate dosages
Is not capable of dispensing own medication

Ability to Handle Finances
Manages financial matters independently; collects and keeps track of income
Manages day-to-day purchases, but needs help with banking, major purchases, etc.
Incapable of handling money