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Form D to be completed by patient INSTRUMENTAL ACITIVITIES OF DAILY LIVING SCALE IADL Circle the number to the right of the statement that best describes your/subject s ability with the following tasks. A. Ability to use telephone 1. Operates telephone on own initiative 1 Looks up and dials numbers 2. Dials a few well-known numbers 3. Answers telephone but does not dial 4. Does not use the telephone at all B. Shopping 1. Takes care of all shopping needs independently 2. Shops independently for small purchases 3. Needs to be accompanied on any shopping trip 4. Completely unable to shop C. Food preparation 1. Plans prepares and serves adequate meals independently 2. Prepares adequate meals if supplied with ingredients 3. Heats serves and prepares meals or prepares meals but does not maintain adequate diet 4. Needs to have meals prepared and served D. Housekeeping 1. Maintains house alone or with occasional assistance i*e* heavy work 2. Performs light daily tasks such as dishwashing bed making maintain acceptable level of cleanliness 4. Needs help with all home maintenance tasks 5. Does not participate in any housekeeping tasks E* Laundry 1. Does personal laundry completely 2. Launders small items i*e* rinses stockings 3. All laundry must be done by others F* Mode of transportation 1. Travels independently on public transport or drives own car 2. Arranges own travel via taxi but does not otherwise use public transport 3. Travels on public transport when accompanied by another 4. Travel limited to taxi or car with the assistance of another 5. Does not travel at all G* Responsibility for own medications 1. Is responsible for taking medication in correct dosages at correct time 2. Takes responsibility if medication is prepared in advance in separate dosages. 3. Is not capable of dispensing own medication H. Ability to handle finances 1. Manages financial matter independently budgets writes checks pays rent bills go to bank collects and keeps track of income. 2. Manages day-to-day purchases but needs help with banking or major purchases 3. Incapable of handling money. A. Ability to use telephone 1. Operates telephone on own initiative 1 Looks up and dials numbers 2. Dials a few well-known numbers 3. Answers telephone but does not dial 4. Does not use the telephone at all B. Dials a few well-known numbers 3. Answers telephone but does not dial 4. Does not use the telephone at all B. Shopping 1. Takes care of all shopping needs independently 2. Shops independently for small purchases 3. Shopping 1. Takes care of all shopping needs independently 2. Shops independently for small purchases 3. Needs to be accompanied on any shopping trip 4. Completely unable to shop C. Food preparation 1. Plans prepares and serves adequate meals independently 2. Needs to be accompanied on any shopping trip 4. Completely unable to shop C. Food preparation 1. Plans prepares and serves adequate meals independently 2. Prepares adequate meals if supplied with ingredients 3. Heats serves and prepares meals or prepares meals but does not maintain adequate diet 4.

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