The Frail Elderly Functional Assessment Questionnaire: Its ...
The Frail Elderly Functional Assessment Questionnaire: Its ...
The Frail Elderly Functional Assessment Questionnaire: Its ...
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Name of the participant:.<br />
ID #:.<br />
Date:<br />
APPENDIX 1: FEFA QUESTIONNAIRE<br />
1. Are you able to walk?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with a cane or walker<br />
c. Yes, with the help of another person<br />
__d. Not at all<br />
2. Can you transfer out of bed?<br />
a. Yes, alone without a transfer board or other assis-<br />
tive device<br />
_ _ b. Yes, with the help of a transfer board or other device<br />
_ _ c. Yes, With the help of one or more than one person<br />
_ _ d. Yes, with the help of both another person and some<br />
assistive device<br />
e. Not at all<br />
3. Are you able to turn over on your side in bed?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with assistive device(s)<br />
_ _ c. Yes, with some help from another person<br />
d. No, must beturned<br />
4. Are you able to wash dishes?<br />
__a. Yes<br />
__b. No<br />
5. Are you able to prepare your own hot dinner?<br />
__a. Yes<br />
_ _ b. No, but am able to heat up already prepared meals<br />
_ _ c. No, but am able to make a peanut butter and jelly<br />
sandwich<br />
_ _ d. Not at all<br />
6. Are you able to manage money (paying bills, keep check-<br />
book, etc)?<br />
__a. Yes<br />
_ _ b. Partially, but not major bills and balancing a check-<br />
book<br />
_ _ c. Sign checks but unable to handle even minor trans-<br />
actions<br />
__d. No<br />
7. Are you able to use the telephone?<br />
_ _ a. Yes, !ncluding dialing and answering the phone<br />
_ _ b. Yes, but unable to dial<br />
_ _ c. Yes, but am not able to dial or pick up receiver<br />
__d. No<br />
8. Are you able to eat by mouth, including feeding your-<br />
self?.<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with assistive device(s)<br />
_ _ c. No, but can eat iffed<br />
d. No, but can give own tube feeding<br />
_ _ e. No, must be tube fed<br />
/<br />
9. Are you able to dress yourself in pants, shirt or blouse, slip<br />
on shoes, and socks if clothes are placed out?<br />
_ _ a. Yes, without help of either a person or assistive<br />
device<br />
_ _ b. Yes, Wth assistive device(s)<br />
_ _ c. Part!ally, but some help is required from another<br />
person<br />
d. No, Completely dependent on another person<br />
FRAIL ELDERLY FUNCTIONAL ASSESSMENT, Gloth 1575<br />
APPENDIX 1: FEFA QUESTIONNAIRE (Cont'd)<br />
10. Are you able to dress yourself in a robe and slippers if<br />
both are placed out?<br />
_ _ a. Yes, without help of either a person or assistive<br />
device<br />
_ _ b. Yes, with assistive device(s)<br />
c. Partially, but some help is required from another<br />
person<br />
d. No, completely dependent on another person<br />
11. Are you able to bathe in a tub or shower yourself?<br />
_ _ a. Yes, without help<br />
_ _ bo Yes, with assistive device(s), eg, tubchair or grab<br />
bar<br />
_ _ c. Partially, but some help is required from another<br />
person<br />
_ _ d. Partially, but some help is required from another<br />
person and assistive device(s)<br />
_ _ e. No, completely dependent on another person<br />
12. If the answer to #11 was 'e' (completely dependent on<br />
another person), are you able to sponge bathe yourself?<br />
_ _ a. Yes, without help<br />
_ _ b. Partially, but some help is required from another<br />
person<br />
_ _ c. No, completely dependent on another person<br />
_ _ d. Not applicable (#11 was a, b, c, or d)<br />
13. Are you able to use the toilet, including getting to the<br />
bathroom?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with assistive device(s)<br />
_ _ c. Yes, with some help from another person<br />
_ _ d. Yes, with help from another person and assistive<br />
device(s)<br />
_ _ e. No, unable to use toilet in the bathroom<br />
If you answered #13 as 'a' (yes, without help) skip to #15.<br />
14. If you answered #13 above as 'e' (unable to use toilet in<br />
the bathroom) are you able to use a bedside commode?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with assistive device(s)<br />
_ _ c. Yes, with some help from another person<br />
d. Yes, with help from another person and assistive<br />
device(s)<br />
_ _ e. No, unable to use bedside commode<br />
_ _ f. Not applicable (#13 was a, b, c, or d)<br />
If you answered #14 as 'a' (yes, without help) skip to #16<br />
15. If you answered #14 above as 'e', unable to use bedside<br />
commode, are you able to use a bedpan/urinal?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with help<br />
_ _ c. No, am unable to recognize bladder fullness or<br />
bowel movement<br />
d. No, have an ostomy (who cares for the site and<br />
empties the bag?. )<br />
_ _ e. Not applicable (#13 or #14 was a, b, c, or d)<br />
16. Are you ableto sit up?<br />
_ _ a. Yes, without help<br />
_ _ b. Yes, with assistive device(s)<br />
_ _ c. Yes, but some help is required from another<br />
person<br />
__d. No<br />
Arch Phys Med Rehabil Vol 80, December 1999
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