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Assessing Your Loved One Checklist

Use this form to assess what tasks or personal care needs your loved one may need currently.
Include your loved one in this assessment if able.

Task/Activity Level of Help Needed
None Some A Lot
Bathing:
Sponge Bath
Shower
Full Bath
Dressing (putting on clothes)
Grooming (hair, shave, teeth)
Assistance with Walking (a person must help):
Uses Walker
Uses Wheelchair
Uses Cane
Getting in and out of bed/chair
Assistance with going to toilet
Incontinence Care (adult briefs, catheter)
Meal Preparation:
Arrange food on a place, cut food
Place food in mouth
Other:
Medication Reminders (remind of times to take pills)
Medication Organization (sort/place pills in dispenser) Not Applicable
Socializing (how much are they interacting w/ others)
Shopping (groceries, clothes)
Light Housekeeping
Doing Laundry
Handling the mail
Scheduling Doctor's Appointments
Providing Transportation (driving)
Managing Medications (order refills)
Managing Money (pay bills) Not Applicable
Handling Household Chores (garbage, repairs)
Handing Health Insurance Matters
Number of Hours can be left alone
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