Home Care Self-Assessment

The purpose for this home care self-assessment worksheet is to help evaluate a senior’s ability to live safely and productively at home. Going through this worksheet will not only help identify ADLs (activities of daily living) they need help with, but also help them arrive to a decision they need help, which in the end is the toughest decision to make - accepting help in the home. For more information on ADLs, click here.

This information will be evaluated by a registered nurse as part of a formal assessment for home care. We recommend if the family is actively working with their loved one that both family members and the senior fill out this worksheet if the senior is not capable of going through the worksheet; a family member can go through the worksheet as a helpful aid prior to a discussion with Aware Senior Care




Please rate the level of Assistance for each of the independent activities of daily living (IADLS) described below:

Managing Finances Assistance Need

0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance

Please rate the level of Assistance for each of the activities of daily living (ADLs) described below


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance
At All Times
Mornings
Afternoons
Evenings/Bedtime


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance

At All Times
Mornings
Afternoons
Evenings/Bedtime


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance

At All Times
Mornings
Afternoons
Evenings/Bedtime


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance

Always
Mornings
Evenings


0 - Independent
1 - Minimum Assistance
2 - Moderate Assistance
3 - Total Assistance
Mornings
Afternoons
Evenings

Please comment on behavior and State of Mind

Your Contact Information

 
 

Evaluating Your Score:

0-7 Support services may not be needed at this time

8-14 Consider support services for safety and to maintain independence

15-20 Support services strongly recommended for safety and to maintain independence

>20 Support services highly recommended as soon as possible

  Yes