Test Request	Function Tested	Able, Normal	Limited but Able	Unable
Put both hands together, behind your head	Shoulder external rotation, flexion, abduction; elbow flexion; wrist extension; gross strength (managing clothing, hair combing, washing back)
Put both hands together, behind your back	Shoulder internal rotation, adduction; elbow flexion; gross strength (managing clothing, washing lower back)
Sitting, touch great toe with opposite hand	Back, hip, knee flexion, gross strength, balance (lower extremity dressing and hygiene)
Squeeze my two fingers, each hand	Grasp; approximately 20-lb grasp needed for functional activities (e.g., holding a pan)
Hold paper between thumb and lateral side of index finger (while examiner tries to pull it out)	Pinch; approximately 3-lb grip needed for functional activities (e.g., turning a key)
Show me your medicines	Cognition; knowledge; visual acuity, hand function; compliance; polypharmacy; effective management of health problems; access to health care; support system; finances; polyproviders
Get up from the chair without using your hands, walk 10 ft down hall, turn around, stand with your eyes closed (examiner nudges to determine balance), sit down without using hands	Hip strength; gait, symmetry in posture velocity, step height; balance, ability to withstand sudden changes in position; fall risk; cardiovascular and pulmonary status; transfer ability; motion; fear of falls; judgment and cognition; environmental awareness; need for assistance/equipment; flexibility; endurance; ability to walk and function at home
Take off your shoes and socks	Balance; fine motor skills; dexterity; hearing and receptive language; visual acuity; judgment; registration and attention span; low back flexibility and mobility; weight shifting; safety and adequacy of footware; social support if nails are cut by someone else; pain and comfort on movement
Observe a meal being prepared/eaten	Nutritional intake; intactness of reflexes; use of utensils; hand/oral motor function; sequencing skills, visual acuity; use of utensils and equipment; ability to get needed help; ability to handle food and liquid; ability to compensate for limitations
Summary and conclusions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Source: Dr. Cheryl Osborne, EdD, RN, Professor of Nursing, Director of Gerontology, California State University, Sacramento.

NOTE: Totally independent—total score of 9 in Able or Limited columns; dependent >1 in Unable column.