Let's see how you can take care of yourself

For each area of functioning listed below check description that applies. (The word assistance means supervision, direction or personal assistance)

Put your assigned number(Required)

Do not put your name for privacy reasons.

BATHING – either sponge bath, tub, or shower

I do not need any assistance

I need assistance with only 1 body part

I need assistance with more than 1 body part

DRESSING – gets clothes from closet and drawers including under-clothes

I can get clothes & get completely dressed independently

I can gets clothes & get dressed except for shoes/socks

I must receive assistance on choosing clothes or getting dressed

TOILETING-going to the toilet for bowel and bladder emptying

Independent with toileting

I should receive assistance with getting to toilet and/or cleaning self

I must use bedpan

TRANSFERING-in and out of bed and to chair

I can transfer without assistance (may use assistive device such as cane, walker)

I can transfer with assistance

Unable to assist with transfer /Bedbound

FEEDING

Feed myself without assistance

Feed myself except for cutting meat or buttering bread

I receive assistance in feeding, or hand fed, tube, IV

CONTINENCE

Fully control Bowel & Bladder

Have occasional “accidents”

Incontinent, briefs or catheter used

ABILITY TO USE TELEPHONE

I can work with phone on my own

I can try to dial but it is difficult

I can answer telephone but do not dial

I do not use telephone at all

SHOPPING

I can take care of all shopping needs

I can shop independently for small purchases

I need to be accompanied on shopping trips

Completely unable to shop

HOUSEKEEPING

I can maintain house alone or with occasional assistance

I can perform light daily tasks adequately

I can perform light daily tasks but not adequately

I need help with all home maintenance tasks

I do not participate an any housekeeping tasks

FOOD PREPARATION

I can prepare and serve adequate meals

I can prepare adequate meals if supplied with ingredients

I can prepare meals but I do not maintain adequate diet

I need to have meals prepared & served

LAUNDRY

I do my personal laundry completely

I can do just only small items

All laundry must be done by others

MODE OF TRANSPORTATION

I can travel independently on public transit or car

I can arrange my own travel via taxi or Rideshare (Uber, Lyft)

Traveling is limited to taxi or auto with assistance

I do not travel at all.

MEDICATION MANAGEMENT

I can manage medications independently

I can manage medications if prepared in advance by other (e.g., someone prepares pillbox)

I am not capable of dispensing/remembering to take own medications

FINANCIAL MANAGEMENT

I can manage all finances independently

I can manage daily purchases, but I need assistance with major purchases

I am not capable of managing finances

CAPTCHA

Activities of Daily Living

Let's see how you can take care of yourself