Education |
0 – no formal schooling |
1 – special school or special
education classes |
2 – regular classes, but not at grade level |
3 –
regular school, grade-appropriate for age (within 2 years) |
|
|
Employment |
0 – unable to work/homebound |
1 – sheltered workshop |
2 – special job |
3 – regular job |
|
|
Speech |
0 – no verbal communication |
1 – rare understandable words
with nonverbal communication |
2 – speech understandable with
difficulty |
3 – detectable speech disturbance but readily understood |
4 – normal speech |
|
Feeding |
0 – tube feedings only |
1 – some oral feedings, with
supplemental tube feedings |
2 – oral feedings with consistent changes
in diet |
3 – normal diet with occasional choking |
4 – normal
swallowing |
|
Dressing |
0 – total dependence |
1 – can assist with dressing but
dependent on others |
2 – independent, but with decreased efficiency |
3 - normal |
|
|
Toileting |
0 – total dependence |
1 – needs assistance |
2 –
independent, but with decreased efficiency |
3 – normal |
|
|
Writing |
0 – cannot reach for and grasp writing utensil |
1 – can
reach for and grasp writing utensil, but cannot scribble |
2 – can
scribble, but cannot draw or write letters |
3 – can draw or write
letters |
4 – normal for age |
|
Sitting |
0 – cannot sit without support |
|
2 – can sit without
support |
|
|
|
Walking |
0 – wheelchair or bedbound |
1 – can crawl/bunny hop |
2 –
can walk a few steps, but needs adaptive aids or other support |
3 –
needs adaptive aids to walk 20 feet |
4 – impaired gait, but uses no
assistive devices |
5 – normal gait |
Breathing |
0 – ventilator or constant respiratory support |
1 –
intermittent use of non-invasive respiratory support |
2 – has
respiratory symptoms, but does not use ventilator support |
3 – normal
breathing |
|
|
Total Score (Out of 31 Points) |
Total Score (Out of 31 Points) |
Total
Score (Out of 31 Points) |
Total Score (Out of 31 Points) |
Total Score
(Out of 31 Points) |
Total Score (Out of 31 Points) |
Total Score (Out
of 31 Points) |
Used if beyond school age (instead of education) |
*Used if beyond
school age (instead of education) |
*Used if beyond school age (instead
of education) |
*Used if beyond school age (instead of education) |
*Used if beyond school age (instead of education) |
*Used if beyond
school age (instead of education) |
*Used if beyond school age (instead
of education) |