NM800079 (Rev. 09/26/16) Worksheet Only – Not a Medical Record Document
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Instructions: Circle the scoring point for the statement that most closely corresponds to the patient’s current functional ability
for each task. The examiner should complete the scale based on information about the patient from the patient him-/herself,
informants (such as the patient’s family member or other caregiver), and recent records.
A. Ability to use telephone
1. Operates telephone on own initiative;
looks up and dials numbers, etc.
2. Dials a few well-known numbers
3. Answers telephone but does not dial
4. Does not use telephone at all
1. Takes care of all shopping needs
2. Shops independently for small purchases
3. Needs to be accompanied on any
4. Completely unable to shop
C. Food preparation
1. Plans, prepares, and serves adequate
2. Prepares adequate meals if supplied with
3. Heats and serves prepared meals, or
prepares meals but does not maintain
4. Needs to have meals prepared and served
1. Maintains house alone or with occasional
assistance (e.g. “heavy work domestic help”)
2. Performs light daily tasks such as
dishwashing, bed making
3. Performs light daily tasks but cannot
maintain acceptable level of cleanliness
4. Needs help with all home maintenance
5. Does not participate in any housekeeping
1. Does personal laundry completely
2. Launders small items; rinses stockings, etc.
3. All laundry must be done by others
F. Mode of transportation
1. Travels independently on public
transportation or drives own car
2. Arranges own travel via taxi, but does not
otherwise use public transportation
3. Travels on public transportation when
assisted or accompanied by another
4. Travel limited to taxi or automobile with
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
H. Ability to handle finances
1. Manages financial matters independently
(budgets, writes checks, pays rent and bills,
goes to bank), collects and keeps track of
2. Manages day-to-day purchases, but needs
help with banking, major purchases, etc.
3. Incapable of handling money
(Lawton & Brody, 1969)
Scoring: The patient receives a score of 1 for each item labeled A – H if his or her competence is rated at some minimal level
or higher. Add the total points circled for A – H. The total score may range from 0 – 8. A lower score indicates a higher
level of dependence.
ξ Cromwell DA, Eagar K, Poulos RG. The performance of instrumental activities of daily living scale in screening for cognitive impairment in elderly
community residents. J Clin Epidemiol. 2003;56(2):131-137.
ξ Lawton MP. The functional assessment of elderly people. J Am Geriatr Soc. 1971;19(6):465-481.
ξ Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.
ξ Polisher Research Institute. Instrumental Activities of Daily Living Scale (ADL). Available at: http://www.abramsoncenter.org/PRI/documents/IADL.pdf .
Accessed February 15, 2005.