DATE:           TIME (24hr): 

1. Regarding eating: Which best describes subjects usual performance during the past 4 weeks?
  Ate without physical help
  Used a fork or spoon, but not a knife to eat
  Used fingers to eat
  Usually or always was fed by someone else

2. Regarding walking (or getting around in a wheelchair), in the past 4 weeks,
which best describes his/her optimal performance:
  Mobile outside of home without physical help
  Mobile across a room without physical help
  Transferred from bed to chair without help
  Required physical help to walk or transfer

3. Regarding bowel and bladder function at the toilet, which best describes his/her usual performance in the past 4 weeks:
  Did everything necessary without supervision or help
  Needed supervision, but no physical help, and was usually continent
  Needed physical help, and was usually continent
  Needed physical help, and was usually incontinent

4. Regarding bathing, in the past 4 weeks, which best describes his/her usual performance:
  Bathed without reminding or physical help
  No physical help, but needed supervision/reminders to bathe completely
  Needed minor physical help (e.g., with washing hair) to bathe completely
  Needed to be bathed completely

5. Regarding grooming, in the past 4 weeks, which best describes his/her optimal performance:
  Cleaned and cut fingernails, without physical help
  Brushed or combed hair without physical help
  Kept face and hands clean without physical help
  Needed help for grooming of hair, face, hands, and fingernails

6a. Regarding dressing, in the past 4 weeks:
      Did subject select his/her first set of clothes for the day?
Yes / No / don't know
      
      If Yes, which best describes his/her usual performance:
  Without supervision or help
  With supervision
  With physical help

6b. Regarding physically getting dressed,
      which best describes his/her usual performance in the past 4 weeks: (check one)
  Dressed completely without supervision or physical help
  Dressed completely with supervision, but without help
  Needed physical help only for buttons, clasps, or shoelaces
  Dressed without help if clothes needed no fastening or buttoning
  Always needed help, regardless of type of clothing
  Don’t know

7. In the past 4 weeks, did subject use a telephone
Yes / No / don't know
      
      If Yes, which best describes his/her highest level of performance:
  Made calls after looking up numbers in white or yellow pages, or by dialing directory assistance
  Made calls only to well-known numbers without referring to a directory, list, or preprogrammed numbers
  Made calls only to well-known numbers by using a directory or list
  Answered the phone; did not make calls
  Did not answer the phone, but spoke when put on the line

8. In the past 4 weeks, did subject watch television?
Yes / No / don't know
      
      If Yes, ask each of the following:
     Yes / No
          a. Did subject usually select or ask for different programs or his/her favorite show?
          b. Did subject usually talk about the content of a program while watching it?
          c. Did subject talk about the content of a program within a day (24 hours) after watching it?

9. In the past 4 weeks, did subject ever appear to pay attention to consversation or small talk for at least 5 minutes?
(note subject did not need to initiate the conversation)
Yes / No / don't know
      
If Yes, which best describes his/her usual degree of participation:
  Usually said things what were related to the topic
  Usually said things that were not related to the topic
  Rarely or never spoke

10. Did subject clear the dishes from the table after a meal or snack?
Yes / No / don't know
      
If Yes, which best describes how he/she usually performed:
  Without supervision or help
  With supervision
  With physical help

11. In the past 4 weeks, did subject usually manage to find his/her personal belongings at home?
Yes / No / don't know
      
If Yes, which best describes how he/she usually performed:
  Without supervision or help
  With supervision
  With physical help

12. In the past 4 weeks, did subject obtain a hot or cold beverage for him/herself?
Yes / No / don't know
      
If Yes, which best describes his/her highest level of performance:
  Made a hot beverage, usually without physical help
  Made a hot beverage, usually if someone else heated the water
  Obtained a cold beverage, usually without physical help

13. In the past 4 weeks, did subject make him/herself a meal or snack at home?
Yes / No / don't know
      
If Yes, which best describes his/her highest level of performance:
  Cooked or microwaved food, with little or no help
  Cooked or microwaved food, with extensive help
  Mixed or combined food items for a meal or snack, without cooking or microwaving (e.g., made a sandwich)

14. In the past 4 weeks, did subject dispose of garbage or litter in an appropriate place or container at home?
Yes / No / don't know
      
If Yes, which best describes how he/she usually performed:
  Without supervision or help
  With supervision
  With physical help

15. In the past 4 weeks, did subject get around (or travel) outside of his/her home?
Yes / No / don't know
      
If Yes, which best describes his/her optimal performance:
  Alone, went at least 1 mile away from home
  Alone, but remained within 1 mile of home
  Only when accompanied and supervised, regardless of the trip
  Only with physical help, regardless or the trip

16. In the past 4 weeks, did subject ever go shopping?
Yes / No / don't know
      
If yes, ask A and B
A) Which one best describes how subject usually selects items?
  Without supervision or physical help
  With some supervision or physical help
  Not at all, or selected mainly random or inappropriate items
B) Did subject usually pay for items without supervision or physical help?
  Yes
  No

17. In the past 4 weeks, did subject keep appointments, meetings with other people, such as relatives, a doctor, the hairdresser, etc.?
  Usually remembered, may have needed written reminders, e.g., notes, a diary, or calendar
  Only remembered the appointment after verbal reminders on the day
  Usually did not remember, in spite of verbal reminders on the day

18. In the past 4 weeks, was subject ever left on his/her own?
Yes / No / don't know
      
     If yes, ask all questions:
Was subject left:
     Yes / No
          a) away from home for 15 minutes or longer, during the day?
          b) at home for an hour or longer, during the day
          c) at home, for less than 1 hour during the day

19. In the past 4 weeks, did subject talk about current events? (This means events or incidents that occurred during the past month.)
Yes / No / don't know
      
     If yes, ask all questions:
Did subject talk about events that…:
     Yes / No
          a) he/she heard or read about or saw on TV but did not take part in?
          b) he/she took part in outside home involving family, friends, or neighbors?
          c) events that occurred at home that he/she took part in or watched

20. In the past 4 weeks, did subject read a magazine, newspaper or book for more than 5 minutes at a time?
Yes / No / don't know
      
     If yes, ask all questions:
Did subject usually:
     Yes / No
          a) talk about details of what he/she read while or shortly (less than 1 hour) after reading?
          b) talk about what he/she read 1 hour or longer after reading?

21. In the past 4 weeks, did subject ever write things down?
Yes / No / don't know
      
Note: if subject wrote things only after encouragement or with help, the response should still be ‘Yes’.
If yes, which best describes the most complicated things that he/she wrote:
  Letters or long notes that other people understood
  Short notes or messages that other people understood
  His/her signature or name

22. In the past 4 weeks, did subject perform a pastime, hobby, or game?
Yes / No / don't know
      
If yes, how did subject usually perform his/her most common pastimes:
  Without supervision or help
  With supervision
  With help
  If subject performs hobbies/pastimes only at day care, check here

23. In the past 4 weeks, did subject use a household appliance to do chores?
Examples include washer, dryer, vacuum, dishwasher, toaster, toaster over, range, microwave, food processor
Yes / No / don't know
      
If yes, for the most commonly used appliances, which best describes how subject usually used them:
  Without help, operating more than on-off controls if needed
  Without help, but operated only on-off controls
  With supervision, but no physical help
  With physical help

TOTAL ADCS-ADL:   
(ADCS-ADL maximum score = 30)

24 - 30   normal, depending on age, education, complaints
20 - 23   mild
10 - 19   moderate
1   -   9   severe
0             profound

To calculate estimate of duration of illness from ADL score, click here:    
TIME-INDEX for ADL (estimated years into Alzheimer's disease):


TEXT FOR YOUR RECORDS - click here:

Electronic form developed at the Palo Alto Veterans Affairs Hospital
  by Wes Ashford, M.D., Ph.D., Jerome Yesavage, M.D.
There is no individual or agency that takes responsibility for the results obtained
with this test or this form.