Republic of the Philippines

BILIRAN PROVINCE STATE UNIVERSITY

(formerly Naval State University)
ISO 9001: 2015 CERTIFIED
School of Nursing and Health Sciences

Name: _____________________________________ Age: _______ Sex: ( ) Male ( ) Female

Address: __________________ Marital Status: _________ If widowed, when? ____________
Previous occupation or present employer: ____________________________________________
Occupation: ____________________________________________ If retired, date? ______________
Date of admission/or first contact: ___________________________________________________________
Referral source: _____________________________________________________________________________
Reason for contacting health agency: _________________________________________________

Katz Index of Independence in Activities of Daily Living

Activities Independence Dependence

Points (1 or 0) (1 Point) (0 Points)

NO supervision, direction, or personal WITH supervision, direction,

assistance. personal assistance, or total
care.
BATHING (1 POINT) Bathe’s self completely or needs (0 POINTS) Need help with
help in bathing only a single part of the bathing more than one part of
Points: body such as the back, genital area or the body, getting in or out of
disabled extremity. the tub or shower. Requires
total bathing

DRESSING (1 POINT) Get clothes from closets and (0 POINTS) Needs help
drawers and puts on clothes and outer with dressing self or needs
Points: garments complete with fasteners. May to be completely dressed.
have help tying shoes.

TOILETING (1 POINT) Goes to toilet, gets on and off, (0 POINTS) Needs help
arranges clothes, cleans genital area without transferring to the toilet,
Points: help. cleaning self or uses bedpan
or commode.

TRANSFERRING (1 POINT) Moves in and out of bed or chair (0 POINTS) Needs help in
unassisted. Mechanical transfer aids are moving from bed to chair or
Points: acceptable requires a complete transfer.

CONTINENCE (1 POINT) Exercises complete self-control (0 POINTS) Is partially or

over urination and defecation. totally incontinent of bowel or
Points: bladder

FEEDING (1 POINT) Gets food from plate into mouth (0 POINTS) Needs partial or
without help. Preparation of food may be total help with feeding or
Points: done by another person. requires parenteral feeding.

TOTAL POINTS:

SCORING: A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional
impairment.

Reference: Wallace, W, Skely, Mary, 2017, Katz Index od Independence in Activities of Daily Living

Best Practices in Nursing Care to Older Adults, The Hartford Institute for Geriatric Nursing, New York University, College of
Nursing, www.hartfordign.org.

mged2021