Katz of Independence in Activities of Daily Living Activities Independence Dependence Points (1or0) (1 point) (0 points) No supervision, direction or With supervision, direction or personal personal assistance. assistance or total care BATHING (1 Bathes self (0 POINTS) Need help with bathing completely or needs help in more than one part of the body, Points:___________ bathing only a single part of getting in or out of the tub or shower, the such as the back, genital Requires total bathing area or disabled extremity. DRESSING (1 get clothes from (0 POINTS) Needs help with dressing closet and drawers and puts self or needs to be completely dressed. Point:________________ on cloth and outer garments complete with fasteners. May have help trying shoes TOILETING (1 POINT) goes to toilet, gets (0 POINTS) Needs help transferring to Points:____________ on and off, arranges clothes, the toilet, cleaning self or uses bedpan cleans genital area without or commode. help. TRANSFERRING (1 in and out of (0 POINTS) Needs help in moving from bed or chair unassisted. bed to chair or requires a complete Points: _____________ Mechanical transferred aids transfer. are acceptable CONTINENCE (1 Exercise complete (0 POINTS) Is partially or totally Points:____________ self control over urination and incontinent of bowel or bladder defecation. FEEDING (1 POINT) Gets food from (0 POINTS) needs partial or total help plate into mouth without with feeding or requires parenteral Points:__________ help. Preparation of food may feeding. be done by another person. 6 =Independent, TOTAL POINTS:___________ SCORING: 3 to 5 = Semi 0 to 2 = Dependent –dependent,
Katz of Independence in Activities of Daily Living Activities Points (1or0) Independence (1 point) No supervision, direction or personal assistance. Dependence (0 points) With supervision, direction or personal assistance or total care BATHING Points:___________ (1 Bathes self completely or needs help in bathing only a single part of the such as the back, genital area or disabled extremity. (0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower, Requires total bathing DRESSING Point:________________ (1 get clothes from closet and drawers and puts on cloth and outer garments complete with fasteners. May have help trying shoes (0 POINTS) Needs help with dressing self or needs to be completely dressed. TOILETING Points:____________ (1 POINT) goes to toilet, gets on and off, arranges clothes, cleans genital area without help. (0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode. TRANSFERRING Points: _____________ (1 in and out of bed or chair unassisted. Mechanical transferred aids are acceptable (0 POINTS) Needs help in moving from bed to chair or requires a complete transfer. CONTINENCE Points:____________ (1 Exercise complete self control over urination and defecation. (0 POINTS) Is partially or totally incontinent of bowel or bladder FEEDING Points:__________ (1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person. (0 POINTS) needs partial or total help with feeding or requires parenteral feeding. TOTAL POINTS:___________ SCORING: 6 =Independent, 3 to 5 = Semi –dependent, 0 to 2 = Dependent
SELF-ASSESSMENT-FORM.docx