Eating Habits

1 Eat Less

2 More fussy about food

3 Began to prefer sweet food

4 Eat in edible

5 Excessive thirst

Sleeping pattern

6 Sleep more during the day

7 Wake early for no reason

8 Lose consciousness

9 Insomnia sleeps little


10 Complain of pain after meals

11 Vomit


12 Difficulty breathing in everyday routine

13 Difficulty breathing after unusual exertion

14 Shallow breath puff

15 Breath noisily wheeze

16 Cough persistently


17 Cold hands/feet

18 Skin is unusual colour


19 Incontinent

20 Urinate frequently

21 Urine of unusual color odour

22 Frequent urinary tract infection

Bowel habits

23 Difficulty using bowels

24 Incontinent of faeces

25 Faeces unusual color/odour/consistency


26 Skin easily damaged bruised /marked

27 Changes in warts/mole/ growth

28 Lumps have developed changed


29 More prone to infections

30 Longer than usual recovery

31 Onset of seizures

Health Sub Scale Score
Degree of functional change Sub Score

32 Less able to roll over and get out of bed

33 Less able to sit /stand upright

34 Less able to use arms/hands during any activity

35 Less able to walk climb steps

36 More likely to lose balance/ stumble /fall

37 Change in way person walks

38 Increased difficulties in eating/swallowing/choking /gagging/spillage

39 Increased difficulty manipulating small items in fingers/buttons/spoons/toothbrush

40 Increased difficulty turning on and off taps/turning doorknobs

41 More likely to drop items

Physical Competencies Sub scale score

Degree of functional change
Sub Score


42 More likely to hold items at unusual distance

43 Less reaction to objects moving towards him/her

44 Squints more often

45 Less able to move around objects

46 More tentative when negotiating steps/surfaces

47 Less able to walk in the dark

48 Less responsive to normal speaking voice

49 Less able to follow a verbal request "give me"...

50 Changing responses to noises

51 More likely to talk loudly

52 More likely to repeat questions as if they had not heard answer

Sensory Integration Sub scale score

Degree of functional change


53 Less aware of own name

54 Less able to recognise familiar people /places /objects

55 Less able to find familiar places in the house

56 Less able to follow through an activity such as moving from one room to another for a purpose

57 Less able to understand what is happening when in an unfamiliar environment

58 Less able to distinguish an object and it's use: toothbrush-teeth cleaning/cup-drinking/ shoes wearing not he feet

59 Less able to follow normal sequence of daily routine

60 Less able to cope with changes in daily routine

61 Less able to predict what happens on different days of the week

62 Less able to recall familiar sequences involved in tasks such as dressing/showering/toileting/eating

63 Less able to recall recent events within the hour/day

64 More likely to behave inappropriately in an unusual situation

65 More likely to exhibit private behaviour in public places

66 More likely to put things in inappropriate places

67 More likely to become possessive about household property

68 Less able to find things that are in there usual place

69 More likely to get lost in familiar places

70 Less able to learn something new

71 More easily confused when asked to do two things in sequence

72 Abilities more likely to fluctuate from day to day

73 Less able to make simple choices

74 More likely to talk about things that happened long ago and become preoccupied with old memories

Perceptual Cognitive Sub scale score
Degree of functional change Sub Score

75 More frequent mood changes

76 More withdrawn quieter than usual less interested in usual activities

77 Shows less expression of emotion does not smile/frown

78 Less initiative/motivation

79 More distressed, upset by everyday events/interactions

80 More frustrated annoyed by everyday events/interactions worried fearful

82 More likely to become angry

83 More likely to appear suspicious/distrustful/accusing

84 Complains more about a variety of topics

85 More self centred

86 Less responsive to things happening in the environment

87 Less responsive to people with whom they have an established relationship/ignoring /avoiding

88 Relate differently to people with whom they have an established relationship

89 More argumentative

90 More likely to repeat statements/questions regardless of response

91 More likely to move around restlessly not staying in one place for long

92 More likely to wander away from familiar locations and get lost

93 More likely to wander on outings and get lost

94 More likely to wander during the night instead of sleeping

95 More noisy and verbally disruptive

96 Increase physical aggression to people

97 More destructive towards objects

98 Less cooperative with usual routines/ resists

99 Declining ability to understand what is said or what is happening in the environment

100 Says or repeats unusual or nonsensical things

Social Emotional Sub scale score
Degree of functional change Sub Score

101 Personal hygiene tasks:washing/shaving/ dental care

102 Dressing undressing and selecting clothing

103 Grooming/ brushing hair/use of deodorant/makeup

104 Using the toilet

105 Eating /using cutlery/drinking

106 Preparing a simple drink/snack or meal

107 Household tasks-making bed/helping with dishes/ simple laundry

108 Household safety dangers-using hot water/electrical appliances/sharp objects/locking doors

109 Community safety and dangers-road safety/ travel skills/ avoiding strangers

110 Using community facilities-shop/recreation facilities/bank/restaurant

111 Managing own money identifying coins/notes/change/ making purchases

ADLSub scale score

Degree of Functional Change
Sub Score

Previous Score

Current Score

Person completing assessment
Add signature
Select date
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.