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<head><meta charset="UTF-8"><meta name="viewport" content="width=device-width, initial-scale=1.0"><title>老年人能力评估表</title><style>body {font-family: Arial, sans-serif;line-height: 1.6;margin: 20px;}table {width: 100%;border-collapse: collapse;margin-bottom: 20px;}th, td {padding: 10px;text-align: center;border: 1px solid #ddd;}th {background-color: #f2f2f2;}.form-group {margin-bottom: 20px;}.note {margin-top: 20px;font-size: 14px;color: #555;}</style>
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<body><h1>老年人能力评估表</h1><!-- 状态表格 -->
<h2>状态、感知觉与沟通、社会参与</h2>
<table><thead><tr><th>状态</th><th>感知觉与沟通</th><th>社会参与</th></tr></thead><tbody><tr><td>0 能力完好</td><td><input type="radio" name="perception-communication-0" value="0"> 0 <input type="radio" name="perception-communication-0" value="1"> 1 <input type="radio" name="perception-communication-0" value="2"> 2 <input type="radio" name="perception-communication-0" value="3"> 3</td><td><input type="radio" name="social-participation-0" value="0"> 0 <input type="radio" name="social-participation-0" value="1"> 1 <input type="radio" name="social-participation-0" value="2"> 2 <input type="radio" name="social-participation-0" value="3"> 3</td></tr><tr><td>1 轻度失能</td><td><input type="radio" name="perception-communication-1" value="0"> 0 <input type="radio" name="perception-communication-1" value="1"> 1 <input type="radio" name="perception-communication-1" value="2"> 2 <input type="radio" name="perception-communication-1" value="3"> 3</td><td><input type="radio" name="social-participation-1" value="0"> 0 <input type="radio" name="social-participation-1" value="1"> 1 <input type="radio" name="social-participation-1" value="2"> 2 <input type="radio" name="social-participation-1" value="3"> 3</td></tr><tr><td>2 中度失能</td><td><input type="radio" name="perception-communication-2" value="0"> 0 <input type="radio" name="perception-communication-2" value="1"> 1 <input type="radio" name="perception-communication-2" value="2"> 2 <input type="radio" name="perception-communication-2" value="3"> 3</td><td><input type="radio" name="social-participation-2" value="0"> 0 <input type="radio" name="social-participation-2" value="1"> 1 <input type="radio" name="social-participation-2" value="2"> 2 <input type="radio" name="social-participation-2" value="3"> 3</td></tr><tr><td>3 重度失能</td><td><input type="radio" name="perception-communication-3" value="0"> 0 <input type="radio" name="perception-communication-3" value="1"> 1 <input type="radio" name="perception-communication-3" value="2"> 2 <input type="radio" name="perception-communication-3" value="3"> 3</td><td><input type="radio" name="social-participation-3" value="0"> 0 <input type="radio" name="social-participation-3" value="1"> 1 <input type="radio" name="social-participation-3" value="2"> 2 <input type="radio" name="social-participation-3" value="3"> 3</td></tr></tbody>
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<div class="note"><h3>注：使用结果判定卡时</h3><ul><li>1. 当日常生活活动为0，精神状态、感知觉与沟通有一项为1及以上，或社会参与为2，判定为轻度失能。</li><li>2. 当日常生活活动为1，后三项有一项为0或1，判定为轻度失能；后三项均为2或某一项为3，则判定为中度失能。</li><li>3. 当日常生活活动为2，后三项全部为2或某一项为3，判定为重度失能，否则为中度失能。</li></ul>
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