Activities of Daily Living (ADLs)
Bathing (showering, sponge bath)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Dressing (selecting clothes, putting on/off)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Grooming (hair care, shaving, oral hygiene)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Toileting (getting to/from toilet, hygiene)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Transferring (bed to chair, standing up)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Mobility (walking, use of walker/cane)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Eating (feeding self)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Instrumental Activities of Daily Living (IADLs)
Meal Preparation
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Medication Management (correct dose/time)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Housekeeping (cleaning, laundry)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Managing Finances (paying bills, budgeting)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Using Phone/Technology
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Cognitive & Mental Status
Memory (short-term recall)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Decision-Making Ability
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Orientation (time, place, person)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Ability to Follow Instructions
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Judgement/Safety Awareness
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Signs of Confusion/Disorientation
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Medical & Physical Health
Chronic Condition Management
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Pain Level Management
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Medication Complexity
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Fall Risk
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Strength and Endurance
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Vision and Hearing Limitations
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Behavioral & Emotional Needs
Anxiety or Depression Symptoms
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Mood Stability
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Social Engagement/Isolation
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Behavioral Issues (agitation, wandering)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Willingness to Accept Care
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Safety & Environment
Home Safety (fall hazards, layout)
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Emergency Response Ability
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Proper Use of Assistive Devices
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Risk of Wandering/Elopement
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Fire Safety Awareness
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Caregiver Support/Social Situation
Availability of Family Support
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Reliability of Current Caregivers
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Caregiver Stress/Burnout
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Need for Respite Care
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Living Situation Stability
*
Completely Independent
Needs Minimal Assistance
Needs Moderate Assistance
Needs Significant Assistance
Fully Dependent/Unable to Perform
Your Overall Score 1phg
Your Average Score 26c8