Pediatric Activities of Daily Living (ADL) Assessment Questionnaire
Use this form to describe a child’s daily living abilities and areas where support may be needed. Keep the title exactly as written throughout the form.
Child and Rater Information
Child’s First Name
*
Child’s Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian/Caregiver Name and Relationship
*
Daily Living Assessment
ADL performance rating
*
Rows
Independent
Needs Some Assistance
Needs Full Assistance
Eating/Feeding
1
2
3
Dressing
4
5
6
Bathing/Showering
7
8
9
Grooming
10
11
12
Toileting
13
14
15
Mobility/Transfers
16
17
18
Sleep/Routine Management
19
20
21
Notable difficulties or observations
Eating/Feeding performance
Needs Full Assistance
1
2
3
4
5
6
7
8
9
Independent
10
1 is Needs Full Assistance, 10 is Independent
Dressing performance
Needs Full Assistance
1
2
3
4
5
6
7
8
9
Independent
10
1 is Needs Full Assistance, 10 is Independent
Bathing/Showering performance
Needs Full Assistance
1
2
3
4
5
6
7
8
9
Independent
10
1 is Needs Full Assistance, 10 is Independent
Grooming performance
Needs Full Assistance
1
2
3
4
5
6
7
8
9
Independent
10
1 is Needs Full Assistance, 10 is Independent
Overall Summary
Overall Independence Level
*
Needs full assistance
1
2
3
4
5
6
7
8
9
Fully independent
10
1 is Needs full assistance, 10 is Fully independent
Additional Observations or Concerns
Submit Form
Should be Empty: