Name:
Date:
Scoring criteria:
Evaluator:
Directions: Rate steps of each task using the above criteria. Following each task, recommend
possible step for training. Under comments, note any information regarding the
individuals responsiveness to the task, factors interfering with training and other
considerations.
Example:
Removes pants.
1. Eating
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Comments
ADL Assessment
2
Comments
2. Undressing
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Unties shoes.
Removes shoes.
Removes socks.
Removes coat.
Removes pullover shirt.
Unbuttons shirt.
Removes button-down shirt.
Unzips pants.
Removes pants.
Removes dress or skirt.
Removes underpants.
Removes undershirt.
Removes bra.
ADL Assessment
3
Comments
4. Toileting
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5. Hand Washing
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Turns on water.
Adjusts water temperature.
Wets hands.
Applies soap.
Lathers hands.
Rinses hands.
Turns off water.
Obtains towel.
Dries hands.
Hangs up towel.
Throws paper towel away.
ADL Assessment
____ Gets clothes.
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Comments
Undresses.
Turns on water.
Adjusts water temperature.
Wets washcloth.
Soaps washcloth.
Washes self.
Rinses self.
Wets hair.
Obtains shampoo from container.
Puts shampoo on hair.
Rubs shampoo into hair.
Rinses hair.
Turns water off.
Obtains towel.
Dries self.
Takes dirty clothes and towels to laundry
7. Toothbrushing
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Obtains toothbrush.
Obtains paste.
Unscrews cap from paste.
Wets brush.
Puts paste on brush.
Actively attempts to brush teeth; make
brushing motion.
Brushes front teeth.
Brushes top back teeth.
Brushes bottom back teeth.
Rinses brush.
Puts brush away.
ADL Assessment
____ Plugs in razor.
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Comments
Turns on razor.
Makes movement with razor on face.
Shaves face area.
Shaves throat and neck area.
Turns razor off.
Puts razor away.
Holds comb/brush.
Moves comb/brush through hair.
Combs/brushes top of head.
Combs/brushes sides of head.
Combs/brushes back of head.
Combs/brushes hair neatly.
Obtains make-up.
Applies lipstick.
Applies eye shadow.
Applies eye liner.
Applies mascara.
Applies blush.
Puts make-up away.
ADL Assessment
____ Pours ingredients from container into
bowl/pan.
____ Unscrews lid of jar.
____ Pours liquids with minimal spillage.
____ Uses measuring cup to scoop and transfer
Ingredients from container into bowl.
____ Mixes with spoon.
____ Mixes with hand beater.
____ Mixes with electric mixer.
____ Spreads butter on bread.
____ Cuts bread with a knife.
____ Rinses vegetables.
____ Cuts up vegetables with knife.
____ Combines ingredients into dish as
directed
____ Prepares cereal.
____ Makes simple sandwiches.
____ Makes simple drinks (juice, tea, koolaid).
____ Operates electric can opener.
____ Operates blender.
____ Operates toaster.
____ Operates oven.
____ Operates range.
____ Reads labels, written/pictures directions
____ Understands measurements.
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Comments
ADL Assessment
7
Comments
13. Serving
____ Pours liquid into glass.
____ Transfers hot food from cooking
container to serving dish.
____ Carries food without spillage.
____ Carries liquids without spillage.
____ Spoons out food from dish to plate.
____ Takes appropriate size portions.
____ Passes serving dish to others.
Recommended training step(s): ____________
_______________________________________
_______________________________________
14. Meal cleanup
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ADL Assessment
____ Measures out detergent.
____ Pours detergent into washer.
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Comments
ADL Assessment
9
Comments
ADL Assessment
10
20. Shopping
___ Can purchase simple items, and wait for
Change.
___ Gives the correct amount of money.
___ Can purchase multiple items adding correct
costs.
___ Can find items in store.
___ Can find items from a list.
___ Knows how to ask for help to find something
___ Finds way around store.
___ Waits in line without difficulty.
___ Gives money and waits for change.
___ Shops at convenience store.
___ Shops at grocery store.
___ Shops at Malls.
___ Shops at specialty stores.
___ Can go shopping in several stores without
supervision.
___ Can shop online.
___ Purchases own clothing
___ Purchases own personal items.
___ Can use public restroom.
Recommended training step(s): ____________
_______________________________________
_______________________________________
21. Community/Leisure
___ Can order simple fast food.
___ Can order food from a menu.
___ Eats appropriately in public.
___ Waits effectively in line.
___ Goes to the movies, pays for ticket, orders
food.
___ Rents videos
___ Schedules and attends community events
(concretes, sporting events)
___ Attends community recreation.
Authors: Bill Nason, MS, LLP
Carrie Aldrich, BSBA
ADL Assessment
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ADL Assessment
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ADL Assessment
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ADL Assessment
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29. Work/School
___ Gets up and to school/work on time.
___ Calls if missing or going to be late.
___ Follows time and simple work/school rules.
___ Organizes and turns in homework.
___ Organizes school or work schedule.
___ Is typically on time to classes, from breaks,
lunch, etc.
___ Knows who to ask for help.
___ Can fill out work applications, and handle
ADL Assessment
15
interviews.
___ Can sign up for classes at school.
___ Completes assigned school or work tasks..
___ Listens and takes directions well.
___ Handles criticism.
___ Gets along with co-workers/students.
___ Avoids making rude comments.
___ Dresses appropriately for work/school.
Recommended training step(s): ____________
_______________________________________
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