Activities Of Daily Living History

6. Speech

0 = Normal

1 = Mildly affected. No difficulty being understood.

2 = Moderately affected. Sometimes asked to repeat statements.

3 = Severely affected. Frequently asked to repeat statements.

4 = Unintelligible most of the time.

7. Salivation

0 = Normal

1 = Slight but definite excess of saliva in mouth; may have nighttime drooling.

2 = Moderately excessive saliva with some drooling.

3 = Marked excess of saliva with some drooling.

4 = Marked drooling, requires constant tissue or handkerchief.

8. Swallowing

0 = Normal

1 = Rare choking

2 = Occasional choking

3 = Requires soft food

4 = Requires nasogastric tube or gastrotomy feeding.

9. Handwriting

0 = Normal

1 = Slightly slow or small

2 = Moderately slow or small; all words are legible.

3 = Severely affected; not all words are legible.

4 = The majority of words are not legible.

10. Cutting food

0 = Normal

1 = Somewhat slow and clumsy, but no help needed.

2 = Can cut most food, although clumsy and slow, some help needed.

3 = Food must be cut by someone, but can still feed slowly.

11. Dressing

0 = Normal

1 = Somewhat slow, but no help needed.

2 = Occasional assistance with buttoning, getting arms in sleeves.

3 = Considerable help required but can do some things alone.

4 = Helpless

12. Hygiene

0 = Normal

1 = Somewhat slow, but no help needed.

2 = Needs help to shower or bathe; or very slow in hygienic care.

3 = Requires assistance for washing, brushing teeth, combing hair, and going to bath room.

4 = Foley catheter or other mechanical aids.

13. Turning in Bed

0 = Normal

1 = Somewhat slow and clumsy, but no help needed.

2 = Can turn alone or adjust sheets, but with great difficulty.

3 = Can initiate, but not turn or adjust sheets alone.

4 = Helpless

14. Falling

0 = Normal

1 = Rare falling.

2 = Occasionally falls, less than once per day.

3 = Falls an average of once daily.

4 = Falls more than once daily.

15. Freezing

1 = Rare freezing when walking; may have start-hesitation.

2 = Occasional freezing when walking.

3 = Frequent freezing; occasionally falls from freezing.

4 = Frequent falls from freezing.

16. Walking

0 = Normal

1 = Mild difficulty. May not swing arms or may tend to drag leg.

2 = Moderate difficulty, but requires little or no assistance.

3 = Severe disturbance of walking, requiring assistance.

4 = Cannot walk at all, even with assistance.

17. Tremor (rated for right and left sides separately)

0 = Absent

1 = Slight and infrequently present.

2 = Moderate; bothersome to patient.

3 = Severe; interferes with many activities.

4 = Marked, interferes with most activities.

18. Sensory symptoms

1 = Occasionally has numbness, tingling, or mild aching.

2 = Frequently has numbness, tingling, or aching, not distressing.

3 = Frequent painful sensations.

4 = Excruciating pain.

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