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: frequently occasionally never

Wetting (nights): 3

2

1

Soiling (nights): 3

2

1

Wetting (days): 3

2

1

Soiling (days): 3

2

1

: not at all not up stairs up stairs and elsewhere

Walk with help*: 3

2

1

_{*(note: if this person walks by himself/herself upstairs and elsewhere, please also code ‘3-star’ for ‘walk with help’)}

Walk by himself: 3

2

1

: not at all with help without help

Feed himself: 3

2

1

Wash himself: 3

2

1

Dress himself: 3

2

1

: blind or almost poor normal

Vision: 3

2

1

: deaf or almost poor normal

Hearing: 3

2

1

: never a word odd words only sentences and normal

Speech: 4

3

2

1

If this person talks in sentences, is his/her speech Difficult to understand even by acquaintances, impossible for strangers? Easily understood for acquaintances, difficult for strangers? Clear enough to be understood by anyone?

: nothing a little newspapers and/or books

Reads: 3

2

1

: nothing a little own correspondence

Writes: 3

2

1

: nothing a little understands money values

Counts: 3

2

1

Please check your answers and go on to the next questionnaire.

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