Questions:

1. Overall in the last 30 days, how much difficulty did [name of person] have with self-care, such as washing or dressing herself?
2. In the last 30 days, how much difficulty did [name of person] have in taking care of and maintaining her general appearance (for example, grooming, looking neat and tidy)?

Response categories:

1. None
2. Mild
3. Moderate
4. Severe
5. Extreme

1. [Esi] pays a lot of attention to the way she looks. She requires no assistance with cleanliness, dressing and eating.
   
   
2. [Adjoa] can find her way around the neighborhood and know where her own belongings are kept, but struggles to remember how to get to a place she has only visited once or twice. She is keen to learn new recipes but finds that she often makes mistakes and has to reread several times before she is able to do them properly.
   
   
3. [Araba] is quadriplegic and must be washed, groomed, dressed and fed by somebody else.
   
   
4. [Ekua] can concentrate while watching TV, reading a magazine or playing a game of cards or chess. She can learn new variations in these games with small effort. Once a week she forgets where her keys or glasses are, but finds them within five minutes.
   
   
5. [Aba] is very quick to learn new skills at her work. She can pay attention to the task at hand for long uninterrupted periods of time. She can remember names of people, addresses, phone numbers and such details that go back several years.
   
   
6. [Efua] cannot concentrate for more than 15 minutes and has difficulty paying attention to what is being said to her. Whenever she starts a task, she never manages to finish it and often forgets what she was doing. She is able to learn the names of people she meets but cannot be trusted to follow directions to a store by herself.
   
   
7. [Fatima] takes twice as long as others to put on and take off clothes, but needs no help with ther. Although it requires an effort, she is able to bathe and groom herself, though less frequently than before. She does not require help with feeding.
   
   
8. [Mame] does not recognize even close relatives and gets lost when she leaves the house unaccompanied. Even when prompted, she shows no recollection of events or recognition of relatives. It is impossible for her to acquire any new knowledge as even simple instructions leave her confused.
   
   
9. [Comfort] lives on her own and has no relatives or friends nearby. Because of her arthritis, she is house-bound. She often stays all day in the same clothes that she has slept in, as changing clothes is too painful. A neighbour helps her wash herself.
   
   
10. [Giftie] requires no assistance with cleanliness, dressing and eating. She occasionally suffers from back pain and when this happens she needs help with bathing and dressing. She always keeps herself tidy.