Caregiver Only: Functional Activities Questionnaire
Caregiver, please rate patient's ability using the following scoring system:
• Dependent = 3
• Requires assistance = 2
• Has difficulty but does by self OR never did and would have difficulty now= 1
• Normal OR never did [the activity] but could do now = 0
• Dependent = 3
• Requires assistance = 2
• Has difficulty but does by self OR never did and would have difficulty now= 1
• Normal OR never did [the activity] but could do now = 0