Activity

Examples

Self care, personal hygiene.

Bathing, grooming, dressing, eating, eliminating.

Communication.

Hearing, speaking, reading, writing, using keyboard.

Physical activity.

Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.

Sensory function.

Tactile feeling.

Hand functions.

Grasping, holding, pinching, percussive movements, sensory discrimination.

Travel.

Driving or travelling as a passenger.

Sexual function.

Participating in desired sexual activity.

Sleep.

Having a restful sleep pattern.

Social and recreational.

Participating in individual or group activities, sports activities, hobbies.

BMI

Category

Health Risk

<18

Very underweight

Long-term hazard to health.

18-20

Underweight

Low risk to health.

20-25

Acceptable

Least risk for morbidity and minimal mortality.

25-30

Overweight

Low risk to health.

30-40

Morbid obesity

High degree of risk to health.

% WPI

Primary Criteria

Secondary Criteria

0

Symptoms of upper digestive tract disease with or without anatomic loss or pathologic alteration present.

Continuous drug treatment not required to control symptoms.

10

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

ONE of the following:

• Continuous drug treatment required to control symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions required to control symptoms or signs.

20

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

BOTH of the following:

• Continuous drug treatment required to control symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions required to control symptoms or signs.

30

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

Any ONE of the following:

• Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions do not completely control symptoms, signs or nutritional deficiency;
• Weight loss with a BMI<20.

40

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

Any TWO of the following:

• Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions do not completely control symptoms, signs or nutritional deficiency;
• Weight loss with a BMI<20.

50

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

ALL of the following:

• Continuous drug treatment does not completely control symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions do not completely control symptoms, signs or nutritional deficiency;
• Weight loss with a BMI<20.

60

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

ALL of the following:

• Continuous drug treatment has little effect on symptoms, signs or nutritional deficiency;
• Appropriate dietary restrictions have little effect on symptoms, signs or nutritional deficiency;
• Assistance required with most or all Activities of Daily Living;
• Weight loss with a BMI<20.

70

Symptoms of upper digestive tract disease, with anatomic loss or pathologic alteration present.

ALL of the following:

• Severe impairment of nutritional status uncontrolled by any treatment or dietary restrictions;
• Assistance required with all Activities of Daily Living;
• Weight loss with a BMI<20.

% WPI

Primary Criteria

Secondary Criteria

0

Signs and/or symptoms of colonic or rectal disease occur infrequently, and/or are of brief duration.

No requirement for any of the following as short term treatment:

• Limitation to Activities of Daily Living;
• Restrictive diet;
• Medication.

No systemic manifestations.

Weight and nutrition can be maintained at desirable level.

10

Signs and/or symptoms of colonic or rectal disease occur more frequently, and/or are of longer duration.

Generally no requirement for any of the following as long-term treatment to control disease although may be needed short term:

• Limitation to Activities of Daily Living;
• Restrictive diet;
• Medication.

No systemic manifestations.

Weight and nutrition can be maintained at desirable level.

20

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

Requirement for at least ONE of the following as long-term treatment to control disease:

• Limitation to Activities of Daily Living;
• Restrictive diet;
• Medication.

No systemic manifestations.

Weight and nutrition can be maintained at desirable level.

30

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

Requirement for ALL of the following as long-term treatment to control disease:

• Limitation to Activities of Daily Living;

• Restrictive diet;

• Medication.

No systemic manifestations.

Weight and nutrition can be maintained at desirable level.

40

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

Requirement for ALL of the following as long-term treatment to control disease:

• Limitation to Activities of Daily Living;

• Restrictive diet;

• Medication.

Requirement for ONE of the following:

• Systemic manifestations (for example, fever, anaemia);
• Weight loss with a BMI<20.

50

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

Requirement for ALL of the following as long-term treatment to control disease:

• Limitation to Activities of Daily Living;

• Restrictive diet;

• Medication.

Requirement for BOTH of the following:

• Systemic manifestations (for example, fever, anaemia);
• Weight loss with a BMI<20.

60

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

NONE of the following long-term treatments control the disease:

• Limitation to Activities of Daily Living;

• Restrictive diet;

• Medication.

Requirement for at least ONE of the following:

• Systemic manifestations (for example, fever, anaemia);
• Weight loss with a BMI<20.

70

Objective evidence of colonic or rectal disease, with anatomic loss or alteration.

NONE of the following long-term treatments control the disease:

• Restrictive diet;

• Medication.

Requirement for ALL of the following:

• Systemic manifestations (for example, fever, anaemia);
• Assistance required with ALL Activities of Daily Living;
• Weight loss with a BMI<20.

% WPI

Primary Criteria

Secondary Criteria

0

Signs of organic anal disease are present;

or

There is anatomic loss or alteration.

Incontinence of gas, or mild or intermittent anal symptoms controlled by treatment.

10

Signs of organic anal disease are present;

or

There is anatomic loss or alteration.

Mild incontinence of gas;

and/or

Liquid stool;

and

Mild or intermittent anal symptoms controlled by treatment.

20

Signs of organic anal disease are present;

or

There is anatomic loss or alteration.

Moderate faecal incontinence requiring daily treatment;

and

Continual anal symptoms incompletely controlled by treatment.

30

Signs of organic anal disease are present;

or

There is anatomic loss or alteration.

Moderate faecal incontinence requiring daily treatment;

and

Continual anal symptoms incompletely controlled by treatment.

40

Signs of organic anal disease are present;

or

There is anatomic loss or alteration.

Complete faecal incontinence despite treatment;

and

Signs of organic anal disease with severe symptoms unresponsive or not amenable to treatment.

% WPI

Criteria

10

Colostomy.

15

Ileostomy.

Ileal pouch-anal anastomosis.

20

Jejunostomy.

Gastrostomy.

Oesophagostomy.

% WPI

Primary Criteria

Secondary Criteria

0

Evidence of persistent or intermittent liver disease.

Histologic severity - very mild.

Liver function tests may be normal or mildly abnormal.

No history of jaundice, ascites or bleeding oesophageal varices in the last 3 years.

Good nutritional state.

15

Evidence of persistent liver disease.

Histologic severity - mild.

Biochemistry abnormal.

No history of jaundice, ascites, or bleeding oesophageal varices, in the last 3 years.

Good nutritional state.

30

Evidence of chronic liver disease.

Histologic severity - moderate.

Biochemistry abnormal.

History of jaundice, ascites, or bleeding oesophageal varices, in the last 12 months.

Good nutritional state

40

Evidence of progressive chronic liver disease.

Histologic severity - severe.

Biochemistry abnormal.

History of jaundice, ascites, or bleeding oesophageal varices, in the last 12 months.

Good nutritional state.

Easily fatigued.

50

Evidence of progressive chronic liver disease.

Histologic severity - chronic hepatitis with cirrhosis.

Biochemistry abnormal.

History of jaundice, ascites, and/or bleeding oesophageal varices, in the last 12 months.

Nutritional state adversely affected.

Fatigue and physical weakness.

65

Evidence of progressive chronic liver disease.

Histologic severity - chronic hepatitis with cirrhosis.

Persistent signs of hepatic insufficiency.

Biochemistry abnormal.

History of jaundice, ascites, and/or bleeding oesophageal varices in the last 12 months.

Nutritional state adversely affected.

Profound fatigue and physical weakness.

75

Evidence of advanced and irreparable chronic liver disease.

Histologic severity - chronic hepatitis with cirrhosis.

Persistent signs of advanced hepatic insufficiency.

Biochemistry abnormal.

History of jaundice, ascites, and/or bleeding oesophageal varices, in the last 12 months.

Nutritional state adversely affected.

Profound fatigue and physical weakness.

Assistance required with all Activities of Daily Living.

% WPI

Criteria

0

Cholecystectomy with no biliary tract sequelae.

10

History of biliary type pain without identifiable biliary disease;

or

Documented history of one to three episodes of biliary colic per year with identifiable biliary disease.

20

Documented history of four to six episodes of biliary colic per year with identifiable biliary disease.

30

Documented history of more than six episodes of biliary colic per year with identifiable biliary disease.

40

Permanent irreparable obstruction of the hepatic or common bile duct with recurrent cholangitis or permanent stent.

50

Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice with intermittent hepatic insufficiency.

65

Permanent common bile duct obstruction with progressive liver disease manifest as persistent jaundice and hepatic insufficiency.

75

Permanent and irreparable common bile duct obstruction with advanced liver disease manifest as persistent jaundice and hepatic insufficiency.

% WPI

Criteria

5

Palpable abdominal wall defect with slight protrusion, with increased abdominal pressure, and readily reducible.

10

Palpable abdominal wall defect with frequent or persistent protrusion, with increased abdominal pressure, manually reducible.

25

Palpable abdominal wall defect with persistent, irreducible or irreparable protrusion at the site of defect, limitation to Activities of Daily Living.