freemedforms-emr-resources 0.9.4-1 / usr / share / freemedforms / forms / subforms / geriatrics / iadl / central.xml

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<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE FreeMedForms>

<FreeMedForms>

  <formdescription>
    <!-- Non translatable values -->
    <authors>Eric Maeker, MD</authors>
    <version>0.7.0</version>
    <fmfv>0.7.0</fmfv>
    <cdate>2011-03-15</cdate>
    <lmdate>2011-11-01</lmdate>
    <icon>geriatrics.png</icon>
    <weblink>http://www.geriu.org/uploads/applications/gerilite_ADL_IADL/data/downloads/form_adl_iadl.pdf</weblink>
    <bibliography pmid="6418786">Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983 Dec;31(12):721-7.</bibliography>

    <!-- Translatable values -->
    <license>GPLv3</license>
    <description lang="fr">Activités instrumentales de la vie quotidienne (IADL)</description>
    <description lang="xx">Instrumental Activities of Daily Living</description>
    <category lang="xx">Geriatrics</category>
    <category lang="fr">Gériatrie</category>
    <specialties lang="fr">Gériatrie</specialties>
    <specialties lang="xx">Geriatrics</specialties>
    <updateinfo>
      <updateversion from="0.6.0" to="0.6.01">
        <text lang="fr">Amélioration du processus d'impression.</text>
        <text lang="en">Improvements in the printing process.</text>
      </updateversion>
    </updateinfo>

  </formdescription>


  <MedForm name="Subs::Geriatrics::Autonomy::IADL">
    <label lang="xx">Instrumental Activities of Daily Living</label>
    <label lang="fr">Activités instrumentales de la vie quotidienne (IADL)</label>
    <options>col=2;DontPrintEmptyValues;UseFormNameAsNameSpace</options>

    <Item name="Phone" type="radio">
      <label lang="xx">&lt;b&gt;Téléphone&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">P0</uuid>
        <uuid id="1">P1</uuid>
        <uuid id="2">P2</uuid>
        <uuid id="3">P3</uuid>

        <possible id="0" lang="fr">Se sert du téléphone de sa propre initiative. Recherche des numéros et les compose, etc.</possible>
        <possible id="1" lang="fr">Compose seulement quelques numéros de téléphone bien connus.</possible>
        <possible id="2" lang="fr">Peut répondre au téléphone, mais ne peut pas appeler.</possible>
        <possible id="3" lang="fr">Ne se sert pas du tout du téléphone.</possible>

        <possible id="0" lang="xx">Operates telephone on own initiative; looks up and dials numbers.</possible>
        <possible id="1" lang="xx">Dials a few well-known numbers.</possible>
        <possible id="2" lang="xx">Answers telephone, but does not dial.</possible>
        <possible id="3" lang="xx">Does not use telephone at all.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">1</numerical>
        <numerical id="3">0</numerical>
      </value>
    </Item>

    <Item name="Shopping" type="radio">
      <label lang="xx">&lt;b&gt;Shopping&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Courses&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">S0</uuid>
        <uuid id="1">S1</uuid>
        <uuid id="2">S2</uuid>
        <uuid id="3">S3</uuid>

        <possible id="0" lang="fr">Peut faire toutes les courses nécessaires de façon autonome.</possible>
        <possible id="1" lang="fr">N'est indépendant que pour certaines courses.</possible>
        <possible id="2" lang="fr">A besoin d'être accompagné pour faire ses courses.</possible>
        <possible id="3" lang="fr">Est complètement incapable de faire des courses.</possible>

        <possible id="0" lang="xx">Takes care of all shopping needs independently.</possible>
        <possible id="1" lang="xx">Shops independently for small purchases.</possible>
        <possible id="2" lang="xx">Needs to be accompanied on any shopping trip.</possible>
        <possible id="3" lang="xx">Is completely unable to shop.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
        <numerical id="2">0</numerical>
        <numerical id="3">0</numerical>
      </value>
    </Item>

    <Item name="Food" type="radio">
      <label lang="xx">&lt;b&gt;Preparing food&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Préparer les repas&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">Fd0</uuid>
        <uuid id="1">Fd1</uuid>
        <uuid id="2">Fd2</uuid>
        <uuid id="3">Fd3</uuid>

        <possible id="0" lang="fr">Prévois, prépare et sert les repas de façon indépendante</possible>
        <possible id="1" lang="fr">Prépare les repas si on lui fournit les ingrédients</possible>
        <possible id="2" lang="fr">Est capable de réchauffer les petits plats préparés</possible>
        <possible id="3" lang="fr">A besoin qu’on lui prépare et qu’on lui serve ses repas</possible>

        <possible id="0" lang="xx">Plans, prepares, and serves adequate meals independently.</possible>
        <possible id="1" lang="xx">Prepares adequate meals if supplied with ingredients.</possible>
        <possible id="2" lang="xx">Heats and serves prepared meals or prepares meals, but does not maintain adequate diet.</possible>
        <possible id="3" lang="xx">Needs to have meals prepared and served.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
        <numerical id="2">0</numerical>
        <numerical id="3">0</numerical>
      </value>
    </Item>

    <Item name="HouseKeeping" type="radio">
      <label lang="xx">&lt;b&gt;Housekeeping&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Préparer les repas&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">HK0</uuid>
        <uuid id="1">HK1</uuid>
        <uuid id="2">HK2</uuid>
        <uuid id="3">HK3</uuid>
        <uuid id="4">HK4</uuid>

        <possible id="0" lang="fr">Entretiens seul la maison avec une aide occasionnelle pour les gros travaux</possible>
        <possible id="1" lang="fr">Ne fait que les travaux d’entretien quotidiens</possible>
        <possible id="2" lang="fr">Fais les petits travaux sans parvenir à garder un niveau de propreté suffisant</possible>
        <possible id="3" lang="fr">A besoin d’aide pour toutes les tâches d’entretien du domicile	</possible>
        <possible id="4" lang="fr">Ne participe pas du tout à l’entretien du domicile</possible>

        <possible id="0" lang="xx">Maintains house alone or with occasional assistance (e.g., heavy-work domestic help).</possible>
        <possible id="1" lang="xx">Performs light daily tasks such as dishwashing, bed making.</possible>
        <possible id="2" lang="xx">Performs light daily tasks, but cannot maintain acceptable level of cleanliness.</possible>
        <possible id="3" lang="xx">Needs help with all home maintenance tasks.</possible>
        <possible id="4" lang="xx">Does not participate in any housekeeping tasks.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">1</numerical>
        <numerical id="3">1</numerical>
        <numerical id="4">0</numerical>
      </value>
    </Item>

    <Item name="Laundry" type="radio">
      <label lang="xx">&lt;b&gt;Doing laundry&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Faire la lessive&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">L0</uuid>
        <uuid id="1">L1</uuid>
        <uuid id="2">L2</uuid>

        <possible id="0" lang="fr">Fait toute sa lessive personnelle ou la porte lui-même au pressing</possible>
        <possible id="1" lang="fr">Lave les petites affaires</possible>
        <possible id="2" lang="fr">Toute la lessive doit être faite par d’autres</possible>

        <possible id="0" lang="xx">Does personal laundry completely.</possible>
        <possible id="1" lang="xx">Launders small items (rinses socks, stockings, etc.).</possible>
        <possible id="2" lang="xx">All laundry must be done by others.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">0</numerical>
      </value>
    </Item>

    <Item name="Transportation" type="radio">
      <label lang="xx">&lt;b&gt;Using transportation&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Utilisation des transports&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">T0</uuid>
        <uuid id="1">T1</uuid>
        <uuid id="2">T2</uuid>
        <uuid id="3">T3</uuid>
        <uuid id="4">T4</uuid>

        <possible id="0" lang="fr">Peut voyager seul et de façon indépendante</possible>
        <possible id="1" lang="fr">Peut se déplacer seul en taxi ou par autobus</possible>
        <possible id="2" lang="fr">Peut prendre les transports en commun s’il est accompagné</possible>
        <possible id="3" lang="fr">Transport limité au taxi ou à la voiture avec accompagnement</possible>
        <possible id="4" lang="fr">Ne se déplace pas du tout</possible>

        <possible id="0" lang="xx">Travels independently on public transportation or drives own car.</possible>
        <possible id="1" lang="xx">Arranges own travel via taxi, but does not otherwise use public transportation.</possible>
        <possible id="2" lang="xx">Travels on public transportation when assisted or accompanied by another.</possible>
        <possible id="3" lang="xx">Travel limited to taxi or automobile with assistance of another.</possible>
        <possible id="4" lang="xx">Does not travel at all.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">1</numerical>
        <numerical id="3">0</numerical>
        <numerical id="4">0</numerical>
      </value>
    </Item>

    <Item name="Medication" type="radio">
      <label lang="xx">&lt;b&gt;Taking own medications&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Prendre ses médicaments&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">M0</uuid>
        <uuid id="1">M1</uuid>
        <uuid id="2">M2</uuid>

        <possible id="0" lang="fr">S’occupe lui-même de la prise (dosage et horaire)</possible>
        <possible id="1" lang="fr">Peut les prendre par lui-même s’ils sont préparés à l’avance</possible>
        <possible id="2" lang="fr">Incapable de les prendre de lui-même</possible>

        <possible id="0" lang="xx">Is responsible for taking medications in correct dosages at correct time.</possible>
        <possible id="1" lang="xx">Takes responsibility if medication is prepared in advance in separate dosages.</possible>
        <possible id="2" lang="xx">Is not capable of dispensing own medication.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">0</numerical>
        <numerical id="2">0</numerical>
      </value>
    </Item>

    <Item name="Finances" type="radio">
      <label lang="xx">&lt;b&gt;Handling own finances&lt;/b&gt;</label>
      <label lang="fr">&lt;b&gt;Gérer son budget&lt;/b&gt;</label>
      <options>vertical;labelontop;DontPrintEmptyValues</options>
      <value>
        <uuid id="0">Fi0</uuid>
        <uuid id="1">Fi1</uuid>
        <uuid id="2">Fi2</uuid>

        <possible id="0" lang="fr">Totalement autonome (fait des chèques, paye ses factures,...)</possible>
        <possible id="1" lang="fr">Se débrouille pour les dépenses au jour le jour, mais a besoin d’aide pour gérer à long terme</possible>
        <possible id="2" lang="fr">Incapable de gérer l’argent nécessaire à payer ses dépenses au jour le jour</possible>

        <possible id="0" lang="xx">Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income.</possible>
        <possible id="1" lang="xx">Manages day-to-day purchases, but needs help with banking, major purchases, etc.</possible>
        <possible id="2" lang="xx">Is incapable of handling money.</possible>

        <numerical id="0">1</numerical>
        <numerical id="1">1</numerical>
        <numerical id="2">0</numerical>
      </value>
    </Item>

    <Item name="Total" type="sum">
      <label lang="fr">&lt;b&gt;Résultat&lt;/b&gt;</label>
      <label lang="xx">&lt;b&gt;Total&lt;/b&gt;</label>
      <options>vertical;labelontop;changeepisodelabel;DontPrintEmptyValues</options>
      <sumof_regexp>Subs::Geriatrics::Autonomy::IADL::*</sumof_regexp>
    </Item>

 </MedForm>

</FreeMedForms>

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