DATE:

Physical Therapy: of Daily Living Checklist

Please check if the task is easy or difficult to complete. If it is an activity you do not do or have never done check not applicable
TASK Shoes Socks Bathing: Bath / Shower / Sponge Bathng Brush teeth Wash/Fix Hair Reach overhead Where do you sleep? Bed / Recliner / Other Sleeping Ironing Vacuum Mop/Sweep Wash Dishes Laundry Make bed Cook How much weight can you lift off the floor to waist level? Lifting Housework Yardwork Kneeling Squatting Driving Grocery shopping Stairs How long can you do the following task's before you have to sit and rest? Walking : Walking Standing Sitting Standing : Sitting :
Easy to complete Mild Difficulty
Moderate Difficulty Severe Difficulty Unable to Complete

Not Applicable

Maximum score is 100 points

Patient Score:

Therapist Signature

Instructions: To score the ADL's points are awarded as follows:

Easy to complete Mild Difficulty Moderate Difficulty Severe Difficulty Unable to Complete Not Applicable

-4

FECHA:

Terapia Fisico:Lista de Actividades de Vivindo Cada Dia Por favor marque si hacendo cada tarea es facil or dificil para completar. Si usted no tiene tiene o nunca a hecho el actividad marque no aplica. TAREA Zapatos Calcetines Banarse: Bano / Derramar / Esponja Banarse Limpiar los dientes Lavar/arreglar pelo Alcanzar de arriba Donde duermes? Cama / Mueble de Reclinar / Otro Dormendo Planchar Aspirar Estropajo/Barrer Lavar Platos Lavar ropia Hacer la cama Cocinar Que tanto peso puedes levantar des del pieso hasta el cintura? Levantar Trabajo de la casa Trabajo de la jardin Arrodillarse Cuclillarse Manehando Comprar el mandado Escaleras Que tanto puedes a durar haciendo cada tarea antes de descansar? Caminando : Caminando Ponerse de pie Sentarse Ponserse de pie : Sentarse :
Facil para completar

Dificil Suave

Dificil Moderado

Dificil Severo Incapaz de Completar

No Aplica