CareLiving, LLC
"Assessing Needs"
This worksheet will help you / family determine what types or areas of assistance are needed.
Activities of Daily Living ( ADL's )
| Activity | Accomplishes Alone | Needs Some Help | Needs Much Help |
Mobility / Cane / Walker / Wheelchair | | | |
Getting out of Bed / Chair | | | |
Relaxation Activities / Remote Control Dexterity | | | |
Bathing / Toileting | | | |
Medication Organization / Dispensing | | | |
Dressing / Grooming / Hygiene | | | |
Eating a Nutritious Diet | | | |
Instrumental Activities of Daily Living ( IADL's )
| Activity | Accomplishes Alone | Needs Some Help | Needs Much Help |
Using the Telephone / Handling Scams | | | |
Shopping for Groceries / Personal Items | | | |
Transportation | | | |
Managing Money / Bill Paying | | | |
Doing Light Housework / Laundry | | | |
Preparing Meals | | | |
Conditions / Functional Status
How do the following affect the person's ability to function?
| Limitation | No Effect | Some Effect | Major Effect |
Hearing | | | |
Vision | | | |
Perception | | | |
Orientation | | | |
Thinking | | | |
Memory | | | |
Decision-Making / Judgment | | | |
Physical Dexterity | | | |
Balance | | | |
Strength | | | |
Energy | | | |
Bladder or Bowel Control | | | |
Arthritis | | | |
Hypertension | | | |
Heart Disease | | | |
Diabetes | | | |
Physical Deformity | | | |
Depression | | | |
| Environmental Safety | No Problem | Existing Barrier | Changes to be Made |
Neighborhood: | | | |
Curb Appeal | | | |
Safe / Lit / Active | | | |
Friends / Relatives Nearby | | | |
Residence Visible / Address Prominent
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Living Quarters
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Heating / Air Conditioning | | | |
Floors Non-skid / Even / No loose Rugs | | | |
Security System / Safety Info Avail | | | |
Adequate Lighting / Switches Accessible | | | |
Locks / Deadbolts | | | |
Peepholes in Doors | | | |
Window Locks / No Bars | | | |
Residence Visible / Address Prominent | | | |
Smokes Alarms Installed / Tested | | | |
Passageways Clear / Accessible / Lit | | | |
Roof / Windows
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Stairs: | | | |
Free of Obstacles / Clutter | | | |
Handrails on Both Sides | | | |
Good Repair / Non-skid | | | |
Kitchen / Bathroom: | | | |
Lever Handles on all Sinks | | | |
Non-Slip Mats | | | |
Often Used Items Easily Accessible | | | |
Storage Easily Accessible | | | |
No Objects Over Stove or Bathtub | | | |
Very Well Lit | | | |
Grab Bars to Studs in Shower / Bathtub | | | |
Non-Skid Strips on Tub / Shower Floor | | | |
Hand-Held Shower Head | | | |