Social Resources Rating Scale

Rate the current social resources of the person being evaluated along the six-point scale presented below. Circle the one number that best describes the person’s present circumstances.

1. Excellent social resources. Social relationships are very satisfying and extensive; at least one person would take care of him or her indefinitely.
2. Good social resources. Social relationships are fairly satisfying and adequate, and at least one person would take care of him or her indefinitely; or social relationships are very satisfying and extensive, and only short-term help is available.
3. Mildly socially impaired. Social relationships are unsatisfactory, of poor quality, few, but at least one person would take care of him or her indefinitely; or social relationships are fairly satisfactory, adequate, and only short-term help is available.
4. Moderately socially impaired. Social relationships are unsatisfactory, of poor quality; few, and only short-term care is available; or social relationships are at least adequate or satisfactory; but help would only be available now and then.
5. Severely socially impaired. Social relationships are of poor quality, few; and help would only be available now and then; or social relationships are at least satisfactory or adequate; but help is not even available now and then.
6. Totally socially impaired. Social relationships are unsatisfactory, of poor quality, few, and help is not even available now and then.

Economic Resources Rating Scale

Rate the current economic resources of the person being evaluated along the six-point scale presented below. Circle the one number that best describes the person’s present circumstances.

1. Economic resources are excellent. Income is ample and person has reserves.
2. Economic resources are satisfactory. Income is ample but person has no reserves; or income is adequate and person has reserves.
3. Economic resources are mildly impaired. Income is adequate but person has no reserves; or income is somewhat inadequate but person has reserves.
4. Economic resources are moderately impaired. Income is somewhat inadequate and person has no reserves.
5. Economic resources are severely impaired. Income is totally inadequate and person may or may not have reserves.
6. Economic resources are completely impaired. Person is destitute, completely without income or reserves.

Mental Health Rating Scale

Rate the current mental functioning of the person being evaluated along the six-point scale presented below. Circle the one number that best describes the person’s present functioning.

1. Outstanding mental health. Intellectually alert and clearly enjoying life. Manages routine and major problems with ease and is free from any psychiatric symptoms.
2. Good mental health. Handles both routine and major problems satisfactorily and is intellectually intact and free of psychiatric symptoms.
3. Mildly mentally impaired. Has mild psychiatric symptoms and/or mild intellectual impairment. Continues to handle routine, though not major, problems satisfactorily.
4. Moderately mentally impaired. Has definite psychiatric symptoms and/or moderate intellectual impairment. Able to make routine commonsense decisions, but unable to handle major problems.
5. Severely mentally impaired. Has severe psychiatric symptoms and/or severe intellectual impairment that interferes with routine judgments and decision making in everyday life.
6. Completely mentally impaired. Grossly psychotic or completely impaired intellectually. Requires either intermittent or constant supervision because of clearly abnormal or potentially harmful behavior.

Physical Health Rating Scale

Rate the current physical functioning of the person being evaluated along the six-point scale presented below. Circle the one number that best describes the person’s present functioning.

1. In excellent physical health. Engages in vigorous physical activity, either regularly or at least from time to time.
2. In good physical health.No significant illnesses or disabilities. Only routine medical care such as annual checkups required.
3. Mildly physically impaired. Has only minor illnesses and/or disabilities that might benefit from medical treatment or corrective measures.
4. Moderately physically impaired. Has one or more diseases or disabilities that are either painful or require substantial medical treatment.
5. Severely physically impaired. Has one or more illnesses or disabilities that are either severely painful or life-threatening or require extensive medical treatment.
6. Totally physically impaired. Confined to bed and requires full-time medical assistance or nursing care to maintain vital bodily functions.

Performance Rating Scale For Activities of Daily Living (ADL)

Rate the current performance of the person being evaluated on the six-point scale presented below. Circle the one number that best describes the person’s present performance.

1. Excellent ADL capacity. Can perform all ADL without assistance and with ease.
2. Good ADL capacity. Can perform all ADL without assistance.
3. Mildly impaired ADL capacity. Can perform all but one to three ADL. Some help is required with one to three, but not necessarily every day. Can get through any single day without help. Is able to prepare own meals.
4. Moderately impaired ADL capacity.Regularly requires assistance with at least four ADL but is able to get through any single day without help; or regularly requires help with meal preparation.
5. Severely impaired ADL capacity. Requires help each day but not necessarily throughout the day or night with many ADL.
6. Completely impaired ADL capacity. Requires help throughout the day and/or night to carry out ADL.

Source: Adapted from University of California Davis Medical Center, Alzheimer's Center, Sacramento, California.