| Physical condition | Mental condition | Activity | Mobility | Incontinent | Total Score | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Good | 4 | Alert | 4 | Ambulant | 4 | Full | 4 | Not | 4 | ||||
| Fair | 3 | Apathetic | 3 | Walk-help | 3 | Slightly limited | 3 | Occasional | 3 | ||||
| Poor | 2 | Confused | 2 | Chair-bound | 2 | Very limited | 2 | Usually-Urine | 2 | ||||
| Very bad | 1 | Stupor | 1 | Stupor | 1 | Immobile | 1 | Doubly | 1 | ||||
| Name | Date | ||||||||||||