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Donald S. Marks, M.D., P.C.

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Caregiver Only: Barthel Index Form

Caregiver, please choose the score which best describes the patient. Do not use any other numbers. 

• Patient Name
• First Name
• Last Name
• Feeding 0 = unable
  5 = Needs helping cutting, spreading butter, ect. OR requires modified diet
  10 = Independent
• Bathing 0 = Dependent
  10 = Independent (or in shower)
• Grooming 0 = Needs help with personal care
  5 = Independent face/hair/teeth/shaving(implements provided)
• Dressing 0 = Dependent
  5 = Needs help, but can do about half unaided
  10 = Independent (including buttons, zips, laces, ect.)
• Bowels 0 = Incontinent (or needs to be given enemas)
  5 = Occasional accident
  10 = Continent
• Toilet Use 0 = Dependent
  5 = Needs some help, but can do things alone
  10 = Independent (on and off dressing, wiping)
• Transfers (Bed to chair and back) 0 = Unable, no sitting balance
  5 = Major help (one or two people physical), can sit
  10 = Minor help (verbal or physical)
  15 = Independent
• Mobility (on level surfaces) 0 = Immobile or < 50 yards
  5 = Wheelchair independent, including corners, > 50 yards
  10 = Walks with help of one person (physical or verbal) > 50 yards
  15 = Independent (but may use any aid - ex. stick) > 50 yards
• Stairs 0 = Unable
  5 = Needs help (verbal, physical, carrying aid)
  10 = Independent

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Donald S. Marks, M.D., P.C. -- 45 Resnik Road, Suite 205 -- Plymouth, MA, 02360

Tel: (508) 746-5060   Fax: (508) 746-8060