Table 5 Structure of daily performance score sheet
These questions concern your current everyday activities. Please circle the appropriate number (1 only for each question) | ||||
Category of numbers | ||||
1. I cannot do it | ||||
2. I can do it, but I do not | ||||
3. I do it, but it is difficult or feels inconvenient | ||||
4. I do it on a daily basis, without any problems | ||||
Can you: | ||||
a) Go to the hospital or meetings by yourself? | 1 | 2 | 3 | 4 |
b) Cross busy roads? | 1 | 2 | 3 | 4 |
c) Walk continuously for about 20 minutes? | 1 | 2 | 3 | 4 |
d) Go out a walk without using a stick? | 1 | 2 | 3 | 4 |
e) Walk and move around indoors without using a handrail? | 1 | 2 | 3 | 4 |
f) Walk up and down stairs without using a handrail? | 1 | 2 | 3 | 4 |
g) Put on your socks while standing up? | 1 | 2 | 3 | 4 |
h) Get into and out of the bath without using a handrail? | 1 | 2 | 3 | 4 |
I) Use a low stool for showering without using a handrail? | 1 | 2 | 3 | 4 |
j) Use a Western-style toilet(chair-type) without using a handrail? | 1 | 2 | 3 | 4 |
k) Use a Japanese-style(squatting-type) toilet without using a handrail? | 1 | 2 | 3 | 4 |
l) Use a bicycle? | 1 | 2 | 3 | 4 |
m) Use the public bus? | 1 | 2 | 3 | 4 |
n) Use the train? | 1 | 2 | 3 | 4 |
o) Use a car (including a taxi)? | 1 | 2 | 3 | 4 |
p) Carry a futon with both hands? | 1 | 2 | 3 | 4 |
q) Wipe the floor with a floor cloth by hand in the kneeling position? | 1 | 2 | 3 | 4 |
r) Use a broom or vacuum cleaner? | 1 | 2 | 3 | 4 |
s) Wipe a table or desk with a cloth? | 1 | 2 | 3 | 4 |
t) Tightly wring out a wet towel? | 1 | 2 | 3 | 4 |
u) Make a cup of tea or instant noodles? | 1 | 2 | 3 | 4 |
v) Use the telephone? | 1 | 2 | 3 | 4 |
w) Write a letter? | 1 | 2 | 3 | 4 |