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<title>老年人能力评估表</title>
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body {
font-family: Arial, sans-serif;
line-height: 1.6;
margin: 20px;
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table {
width: 100%;
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text-align: center;
border: 1px solid #ddd;
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th {
background-color: #f2f2f2;
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.note {
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<h1>老年人能力评估表</h1>
<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>
</table>
<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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</body>
</html>
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