Activities and Daily Living

              OARS Multidimensional Functional Assessment Questionnaire

              Informant


              Please complete the following information:

                First Name: Last Name:
                Patient
                Informant/Caregiver
                City: State: Country:
                What is your city, state and country of primary residence?

              PHYSICAL ACITIVITIES OF DAILY LIVING

              Please Select:
              Does he/she eat...
              Does he/she dress and undress his/herself...
              Does he/she take care of his/her own appearance
              (by combing his/her hair, shaivng, etc.)...
              Does he/she get aournd his/her house, apartment, or room...
              Does he/she get into or out of bed...
              Does he/she bathe-that is, take a bath, shower, or sponge bath...
              Does he/she ever have trouble getting to the bathroom on time?
              About how often does he/she wet or soil his/herself during the day or night?

              INSTRUMENTAL ACTIVITIES OF DAILY LIVING

              Please Select:
              Can he/she use the telephone...
              Can he/she get to places out of walking distance...                    
              Can he/she go shopping for groceries...
              Can he/she prepare his/her own meals...
              Can he/she do housework...
              Can he/she do his/her own handyman work...
              Can he/she do his/her own laundry...
              Does he/she currently take or use any medications?
              If YES does he/she take medication...
              If NO could he/she take medication...
              Can he/she manage her own money...

              Please review your answers. Are you ready to submit your survey?