| RPT |
.| .| Katz Index of Independence in Activities of Daily Living-6pt | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | Katz Index of Independence in ADL: <-KATZ ADL->| | Index score possible range is 0 to 6. A score of 6 indicates full function, 4 indicates moderate impairment,
and 2 or less indicates severe functional impairment. | |
| Questions and Answers| | 1. BATHING |
<*Answer_7059*>| 2. DRESSING | <*Answer_7060*>| 3.
TOILETING | <*Answer_7061*>| 4. TRANSFER| <*Answer_7062*>| 5. CONTINENCE|
<*Answer_7063*>| 6. FEEDING| <*Answer_7064*>| | | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment
results should be verified for accuracy and used in conjunction with other diagnostic activities and procedures.| $~
|
