基本資料 HN   

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請依照你的情況填寫下例問卷，如有任何疑問，可詢問在場職員。 B
Specific Level of Functioning
Social Functioning
A. Interpersonal Relationships Highly typical of this person Generally typical of this person Somewhat typical of this person General untypical of this person Highly untypical of this person
1. Accepts contact with others (does not withdraw or turn away)
2. Initates contact with others
3. Communicates effectively (speech & gestures are understandable and to the point)
4. Engages in activites without prompting
5. Participates in groups
6. Forms and maintains friendships
7.Asks for help when needed
B. Social Acceptability Never Rarely Sometimes Frequently Always
8. Verbally abuses others
9. Physically abuses others
10. Destroys property
11. Physically abuses self
12. Is fearful, crying ,clinging
13. Takes property from others without permission
14. Performs repetitive behaviors (packing, rocking, making noise)
Self-Maintenance
C. Personal Care Skills Totally self-sufficient Needs verbal advice or guidance Needs some physical help or assistance Needs substantial help Totally dependent
15. Toileting (use toilet properly; keep self &area clean)
16. Eating (use utensils properly ;eating habits)
17. Personal hygiene (body& teeth; general cleanliness)
18. Dressing self (dress self.selects appropriate garments)
19. Grooming (hair, make-up, general appearance)
20. Care of own possessions
21. Care of own living space
Community Living Skills
D. Activities Totally self-sufficient Needs verbal advice or guidance Needs some physical help or assistance Needs substantial help Totally dependent
22. Household responsibilities (house cleaning, cooking, washing clothes)
23. Shopping (selection of items, choice of stores, payment at register)
24. Handling personal finances (budgeting, paying bills)
25. Use of telephone (getting number, dialing, speaking, listening)
26. Travelling from residence without getting lost
27.Use of public transportation (selecting route ,using timetable ,paying fares ,making transfer)
28. Use of leisure time (reading, visiting friends, listening music)
29. Recognizing and avoiding common dangers (traffic safety, fire safety)
30. Self- medication (understanding purpose ,taking as prescribed, recognizing side effect)
31.Use of medical and other community services (knowing whom to contact, how, and when to use)
32.Basic reading, writing & arithmetic (enough for daily needs)
     
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