ADL Assessment 1

Name: Date: Evaluator:

Scoring criteria: 2 – The individual performs the task independently, without assistance.
1 – The individual actively performs the task with some assistance.
0 – The individual perform the task; requires complete assistance.

Directions: Rate steps of each task using the above criteria. Following each task, recommend
possible step for training. Under comments, note any information regarding the
individual’s responsiveness to the task, factors interfering with training and other
considerations.

Example: Removes pants. 2 – Takes pants off independently.

1– Actively attempts to remove pants with prompting.
0 – Requires total guidance; makes no attempt to remove pants.

1. Eating
Comments
____ Swallows ground food.
____ Chews food before swallowing.
____ Bites.
____ Finger feeds snack items. CCo
____ Picks up spoon.
____ Scoops food to mouth.
____ Removes food from spoon with lips.
____ Places spoon on table.
____ Feeds self with spoon with minimal spillage.
____ Drinks from glass when glass is held.
____ Holds onto glass when drinking.
____ Drinks without gulping.
____ Drinks with minimal spillage.
____ Takes appropriate size bites.
____ Feeds self with minimal spillage.
____ Eats at appropriate pace.
____ Eats without choking.
____ Eats with fork.
____ Wipes mouth with napkin.
____ Cuts meat with knife.

Recommended training step(s): ______________

_________________________________________
_________________________________________

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 2

Comments
2. Undressing

____ Unties shoes.

____ Removes shoes.
____ Removes socks.
____ Removes coat.
____ Removes pullover shirt.
____ Unbuttons shirt.
____ Removes button-down shirt.
____ Unzips pants.
____ Removes pants.
____ Removes dress or skirt.
____ Removes underpants.
____ Removes undershirt.
____ Removes bra.

Recommended training step(s): ____________

_______________________________________
_______________________________________

3. Dressing

____ Picks out clothes.

____ Puts on underpants.
____ Puts on undershirt.
____ Puts on bra.
____ Fastens bra.
____ Correctly orients clothes before putting
on.
____ Puts feet into pants.
____ Pulls pants up.
____ Puts on pullover shirt.
____ Puts on button-down shirt.
____ Buttons shirt.
____ Tucks in shirt.
____ Fastens pants.
____ Zips up pants.
____ Loops belt into pants.
____ Buckles belt.
____ Puts on socks.
____ Puts on shoes.
____ Ties shoes.

Recommended training step(s): ____________

_______________________________________
_______________________________________

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 3

Comments

4. Toileting

____ Stays dry for two hours.

____ Stays dry during the day.
____ Stays dry at night.
____ Has two or less BM accidents a week.
____ Rarely has toileting accidents.
____ Unfastens pants.
____ Pulls pants down.
____ Sits on toilet.
____ Voids within 15 minutes.
____ Wipes self.
____ Pulls underpants up.
____ Pulls pants up.
____ Fastens pants.
____ Flushes toilet.
____ Washes hands.
____ Goes to toilet with reminders.
____ Self-initiates toileting.

Recommended training step(s): ____________

_______________________________________
_______________________________________

5. Hand Washing

____ Turns on water.

____ Adjusts water temperature.
____ Wets hands.
____ Applies soap.
____ Lathers hands.
____ Rinses hands.
____ Turns off water.
____ Obtains towel.
____ Dries hands.
____ Hangs up towel.
____ Throws paper towel away.

Recommended training step(s): ____________

_______________________________________
_______________________________________

6. Bathing

____ Obtains towel and washcloth from closet.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 4

____ Gets clothes. Comments

____ Undresses.
____ Turns on water.
____ Adjusts water temperature.
____ Wets washcloth.
____ Soaps washcloth.
____ Washes self.
____ Rinses self.
____ Wets hair.
____ Obtains shampoo from container.
____ Puts shampoo on hair.
____ Rubs shampoo into hair.
____ Rinses hair.
____ Turns water off.
____ Obtains towel.
____ Dries self.
____ Takes dirty clothes and towels to laundry

Recommended training step(s): ____________

_______________________________________
_______________________________________

7. Toothbrushing

____ Obtains toothbrush.

____ Obtains paste.
____ Unscrews cap from paste.
____ Wets brush.
____ Puts paste on brush.
____ Actively attempts to brush teeth; make
brushing motion.
____ Brushes front teeth.
____ Brushes top back teeth.
____ Brushes bottom back teeth.
____ Rinses brush.
____ Puts brush away.
____

Recommended training step(s): ____________

_______________________________________
_______________________________________

8. Shaving

____ Obtains razor.

____ Holds razor.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 5

____ Plugs in razor. Comments

____ Turns on razor.

____ Makes movement with razor on face.
____ Shaves face area.
____ Shaves throat and neck area.
____ Turns razor off.
____ Puts razor away.

Recommended training step(s): ____________

_______________________________________
_______________________________________

9. Hair combing/brushing

____ Holds comb/brush.

____ Moves comb/brush through hair.
____ Combs/brushes top of head.
____ Combs/brushes sides of head.
____ Combs/brushes back of head.
____ Combs/brushes hair neatly.

Recommended training step(s): ____________

_______________________________________
_______________________________________

10. Make-up

____ Obtains make-up.

____ Applies lipstick.
____ Applies eye shadow.
____ Applies eye liner.
____ Applies mascara.
____ Applies blush.
____ Puts make-up away.

Recommended training step(s): ____________

_______________________________________
_______________________________________

11. Meal preparation

____ Obtains food from refrigerator.

____ Carries items to counter.
____ Obtains cooking utensils/dishes from
cupboard or drawers.
____ Opens box, bag or other food containers

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 6

____ Pours ingredients from container into Comments

bowl/pan.
____ Unscrews lid of jar.
____ Pours liquids with minimal spillage.
____ Uses measuring cup to scoop and transfer
Ingredients from container into bowl.
____ Mixes with spoon.
____ Mixes with hand beater.
____ Mixes with electric mixer.
____ Spreads butter on bread.
____ Cuts bread with a knife.
____ Rinses vegetables.
____ Cuts up vegetables with knife.
____ Combines ingredients into dish as
directed
____ Prepares cereal.
____ Makes simple sandwiches.
____ Makes simple drinks (juice, tea, koolaid).
____ Operates electric can opener.
____ Operates blender.
____ Operates toaster.
____ Operates oven.
____ Operates range.
____ Reads labels, written/pictures directions
____ Understands measurements.

Recommended training step(s): ____________

_______________________________________
_______________________________________

12. Table Setting

____ Gets placemats, napkins dishes and

utensils from cupboard or drawer.
____ Carries dishes, utensils, etc. to table.
____ Places dishes/utensils on placemat where
staff point to.
____ When given a placemat with pictures or
drawings of dishes/utensils on it, can
match items .
____ Sets complete setting independently.

Recommended training step(s): ____________

_______________________________________
_______________________________________

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 7

Comments

13. Serving

____ Pours liquid into glass.

____ Transfers hot food from cooking
container to serving dish.
____ Carries food without spillage.
____ Carries liquids without spillage.
____ Spoons out food from dish to plate.
____ Takes appropriate size portions.
____ Passes serving dish to others.

Recommended training step(s): ____________

_______________________________________
_______________________________________

14. Meal cleanup

____ Takes dishes to sink.

____ Clears table.
____ Cleans food from plate.
____ Rinses dishes.
____ Places dishes into dishwasher.
____ Puts soap in dishwasher.
____ Turns dishwasher on.
____ Removes dishes from dishwasher.
____ Washes dishes in sink.
____ Dries dishes.
____ Puts dishes/utensils in appropriate
cupboards and drawers.
____ Wipes off table, counter, or chairs.
____ Takes protective clothing to laundry.
____ Sweeps floor.

Recommended training step(s): ____________

_______________________________________
_______________________________________

15. Laundry

____ Takes dirty clothes to laundry.

____ Helps sort clothes by placing clothes in
piles pointed to by staff.
____ Sorts clothes with minimal assistance.
____ Puts clothes into washer.
____ Obtains detergent from cupboard.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 8

____ Measures out detergent. Comments

____ Pours detergent into washer.

____ Sets dial, starts washer.

____ Transfer clothes from washer to dryer.
____ Folds clothes.
____ Takes clothes to bedroom.
____ Puts clothes into drawers.
____ Places clothes on hangers.
____ Hangs clothes up.

Recommended training step(s): ____________

_______________________________________
_______________________________________

15. Bed making

____ Takes blankets/sheets off bed.

____ Spreads sheets/blankets across bed.
____ Smoothes out sheet or blanket.
____ Places pillows appropriately.
____ Spreads bedspread across bed.
____ Completely makes bed.

Recommended training step(s): ____________

_______________________________________
_______________________________________

16. Vacuuming

____ Obtains vacuum from closet.

____ Turns vacuum on and off.
____ Pushes vacuum back and forth.
____ Vacuums small area with supervision.
____ Vacuums entire room

Recommended training step(s): ____________

_______________________________________
_______________________________________

17. Dusting

____ Obtains furniture polish, cloth, etc.

____ Sprays polish.
____ Actively attempts to dust; makes motion
across surfaces.
____ Completely dusts furniture.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 9

Comments

Recommended training step(s): ____________

_______________________________________
_______________________________________

18. Other domestic tasks

____ Helps gets out and puts away activity
materials.
____ Gets mail.
____ Cleans windows/mirrors.
____ Cleans bathtub.
____ Empties wastepaper baskets.
____ Takes out trash.
____ Puts groceries away.
____ Washes vehicle.
____ Shovels snow.
____ Rakes yard.
____ Mows yard.
____ Sweeps garage.

Recommended training step(s): ____________

_______________________________________
_______________________________________

19 Money Skills

___ Understands money has value.

___ Can identify coins.
___ Understand cent value of coins.
___ Can make simple change.
___ Understands denomination of paper money
___ Carry money without losing it.
___ Can purchase simple items up to $10.00.
___ Can purchase items over $20.00.
___ Saves for simple items.
___ Can plan and follow a simple weekly budget
___ Uses savings account; fills out deposit
___ Uses credit or debit card.
___ Takes care of own savings/credit accounts.
___ Writes a check
___ Has addresses and phone numbers of
creditors.
___ Pay bills on time.
___ Avoids money scams.
___ Understands and takes care of entitlement
funds, and social security.
___ Takes care of tax returns.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 10

Recommended training step(s): ____________

_______________________________________
_______________________________________

20. Shopping

___ Can purchase simple items, and wait for

Change.
___ Gives the correct amount of money.
___ Can purchase multiple items adding correct
costs.
___ Can find items in store.
___ Can find items from a list.
___ Knows how to ask for help to find something
___ Finds way around store.
___ Waits in line without difficulty.
___ Gives money and waits for change.
___ Shops at convenience store.
___ Shops at grocery store.
___ Shops at Malls.
___ Shops at specialty stores.
___ Can go shopping in several stores without
supervision.
___ Can shop online.
___ Purchases own clothing
___ Purchases own personal items.
___ Can use public restroom.

Recommended training step(s): ____________

_______________________________________
_______________________________________

21. Community/Leisure

___ Can order simple fast food.

___ Can order food from a menu.
___ Eats appropriately in public.
___ Waits effectively in line.
___ Goes to the movies, pays for ticket, orders
food.
___ Rents videos
___ Schedules and attends community events
(concretes, sporting events)
___ Attends community recreation.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 11

___ Goes with group of friends.

___ Use library

___ Has leisure interests to occupy time

(reading,television, computer, etc.).
___ Adequately organizes own leisure time.

Recommended training step(s): ____________

_______________________________________
_______________________________________

22. Social behavior in public

___ Doesn’t approach stranger inappropriately.

___ Greets others appropriately.
___ Avoids saying rude remarks to strangers.
___ Doesn’t talk loudly at library, church, or
movie.
___ Dresses appropriately for public.
___ Willing to help others if needed.
___ Control anger in public.
___ Avoids obvious stereotypic, self stimulation
behavior in public,
___ Understands simple manners in public
(please, thank you, and sorry)
___ Doesn’t touch people inappropriately, or
invade personal space.

Recommended training step(s): ____________

_______________________________________
_______________________________________

23. Community Mobility

___ Can walk simple distances, with adequate

safety skills.
___ Can cross street safely.
___ Can read street and community signs
___ Can read street and community signs.
___ Has adequate stranger/danger skills.
___ Knows how to seek help.
___ Carries ID
___ Knows own address, telephone number, and
emergency contacts.
___ Can ride public transportation.
___ Can schedule Your-Ride or taxi.
___ Can find way around immediate area.
___ Can find way to frequently visited settings

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 12

(store, post office, barber shop, etc.)

___ Can drive.
___ Can travel around town, within limited
distance.
___ Can travel outside of town using a map.

Recommended training step(s): ____________

_______________________________________
_______________________________________

24. Safety/Medical

___ Tends to minor cuts

___ Takes own medications
___ Uses thermometer to take temperature.
___ Recognizes when medical attention is
needed.
___ Knows who to call in emergencies (911)
___ Can call and make medical appointments.
___ Can fill prescriptions.
___ Careful with hot objects.
___ Careful with sharp objects.
___ Understands and avoids dangers of
electricity.
___ Understand danger of gas and heat (stove,
furnace, etc.).
___ Understands dangers, of simple tools
___ Understands dangers of household
chemicals
___ Can put out simple fires (use extinguisher).

Recommended training step(s)_____________

______________________________________

25. Communication

___ Can use telephone

___ Keeps list of important phone numbers.
___ Can use and maintain a cell phone.
___ Can use internet to find information.
___ Knows email address
___ Can seek out help when needed.

26. Time/Reading/Writing

___ Knows how to tell time.

___ Knows the days of the week.
___ Knows the month and year.
___ Reads simple stories.

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 13

___ Reads newspaper articles.

___ Reads labels.
___ Reads store signs and street signs.
___ Can write or print name, address, and
phone number.
___ Can write or print simple notes.
___ Can write or print letters.
___ Can fill out applications.
___ Can do simple addition and subtraction.

Recommended training step(s): ____________

_______________________________________
_______________________________________

27. Self Direction

___ Remembers to eat all meals.

___ Goes to bed on time, gets enough sleep.
___ Gets up on own in the morning (eg alarm).
___ Gets through morning routine and out the
door for school or work independently.
___ Picks out clothes independently
___ Plans out day, and follows routine.
___ Handles changes in routine.
___ Remembers to do personal maintenance
(change clothes every day, use deodorant,
brush teeth, etc.)
___ Remembers to run errands and do simple
chores.
___ Makes and keeps appointments.
___ Follows a planner, monthly calendar or
other planning tool.
___ Remembers to follow through with
responsibilities/comments.
___ Keep things organized enough not to lose
them.
___ Thinks about consequences before acting.
___ Uses simple problem solving skills when
faced with a simple problem.

Recommended training step(s): ____________

_______________________________________
_______________________________________

28. Self Advocacy/Legal/Financial

___ Understands his own disability including his

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 14

strengths and interests.

___ Is able to communicate his disability to
others.
___ Can ask for support if he needs it.
___ Understands his own vulnerabilities and can
advocate for accommodations.
___ Can assess new situations for light of his
vulnerabilities (sensory issues, social
challenges, etc.)
___ Knows to avoid situations that are above his
skill level.
___ Avoids getting taken advantage of by
strangers, salesmen or phone solicitors.
___ Understands what he is entitled to by the
“American Disabilities Act.”
___ Understands contact sources for disability
services.
___ Can give informed consent for financial,
legal, and medical matters.
___ Knows how to apply for and correspond
with, Social Security, Medicaid, and other
disability funds.
___ Knows how to contact important
government services (Secretary of State)
___ Knows names and phone numbers of
treatment support team members (case
manager, vocational support, psychologist,
doctor, etc.)
___ Facilitates and collaborates in self
determination and treatment strategies.
___ Understand legal responsibilities and
knows how to obtain legal services.

Recommended training step(s): ____________

_______________________________________
_______________________________________

29. Work/School

___ Gets up and to school/work on time.

___ Calls if missing or going to be late.
___ Follows time and simple work/school rules.
___ Organizes and turns in homework.
___ Organizes school or work schedule.
___ Is typically on time to classes, from breaks,
lunch, etc.
___ Knows who to ask for help.
___ Can fill out work applications, and handle

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA
 ADL Assessment 15

interviews.
___ Can sign up for classes at school.
___ Completes assigned school or work tasks..
___ Listens and takes directions well.
___ Handles criticism.
___ Gets along with co-workers/students.
___ Avoids making rude comments.
___ Dresses appropriately for work/school.

Recommended training step(s): ____________

_______________________________________
_______________________________________

Authors: Bill Nason, MS, LLP

Carrie Aldrich, BSBA