Living Well at Home Assessment

The purpose of this 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.

This information will be evaluated 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 Families Choice Home Care.

Please rate the level of Assistance for each of the independent activities of daily living (IADLS) described below:
Managing Finances*
Are there unpaid bills? Bounced checks? Messages from creditors? Is there a stack (or many stacks) of unsorted mail?
- 0 - Independent. Bills consistently paid on time without assistance.
- 1 - Minimum Assistance. Occasional overdraft/overdue bill notices.
- 2 - Moderate Assistance. Many unpaid bills/overdrafts, messages from creditors.
- 3 - Total Assistance. Does not manage own finances.
Managing Finances Comments:
Handling Transportation (Driving)*
Have there been traffic accidents - including fender benders? Are you uncomfortable as a passenger in their car? Have they stopped driving at all? Do you feel safe? Any close calls or unusual variations in speed? Any signs of confusion about where to go?
- 0 - Independent. Drives own vehicle, no accidents or tickets.
- 1 - Minimum Assistance. Has had minor accident, passengers uncomfortable with their driving.
- 2 - Moderate Assistance. More than one accident, gets confused on familiar roads, flustered with traffic.
- 3 - Total Assistance. No longer drives.
Handling Transportation (Driving) Comments:
Shopping*
Are they continually missing essential household items or do they have large amounts of the same item?
- 0 - Independent. Shops independently, prepares list, able to load and unload car.
- 1 - Minimum Assistance. At times, runs out of essential household items, needs help to prepare lists and load/unload car.
- 2 - Moderate Assistance. Consistently missing or has excessive amounts of essential household items, needs assistance preparing lists/while shopping/ loading and unloading car.
- 3 - Total Assistance. No longer shops.
Shopping Comments:
Preparing Meals*
Have they stopped making meals? Are they making poor decisions in what they eat- on a consistent basis? Is there spoiled food in the refrigerator or cabinets?
- 0 - Independent. Makes own nutritious meals without help.
- 1 - Minimum Assistance. Occasionally skips meals/chooses food with little nutritional value.
- 2 - Moderate Assistance. Rarely prepares nutritious meals/consistently makes poor food choices/burned pan on stove.
- 3 - Total Assistance. No longer prepares meals.
Preparing Meals Comments:
Using the Telephone*
Do they answer the phone when you call? Do phone messages go unanswered?
- 0 - Independent. Answers phone consistently, returns voicemail messages consistently.
- 1 - Minimum Assistance. Occasionally misses a phone call or forgets to return voicemail message.
- 2 - Moderate Assistance. Rarely answers the phone or returns voicemail messages.
- 3 - Total Assistance. Does not use the phone.
Using the Telephone Comments:
Managing Medications*
Are they taking too many or too few of their prescribed medicines? Are they unsure what to take or why they are taking it?
- 0 - Independent. Takes medications as prescribed, refills meds, rarely misses a dose.
- 1 - Minimum Assistance. Fills own pillboxes/forgets to take medication 2-3 times/week, occasionally runs out before refilling.
- 2 - Moderate Assistance. Someone else fills pillboxes /forgets to take medication at least once/day.
- 3 - Total Assistance. Someone else fills pillboxes and refills prescriptions/needs constant reminders to take medication throughout the day.
Managing Medications Comments:
Housework and Basic Home Maintenance*
Is the home so cluttered you are concerned they may fall? Has the furniture been dusted, floors vacuumed or mopped? Are there dirty dishes? Are there safety issues due to lack of maintenance- burned out light bulbs, shaky hand railings?
- 0 - Independent. Home is in good repair, no clutter or safety issues.
- 1 - Minimum Assistance. Home needs minor attention- dusting/vacuuming, has burned out light bulbs/dirty dishes, some clutter.
- 2 - Moderate Assistance. Home needs significant attention- rooms including floors are cluttered, stairs/handrails need repair, appliances/HVAC in disrepair/yard overgrown.
- 3 - Total Assistance. Home poses serious hazards- unsafe to live in.
Housework and Basic Home Maintenance Comments:
Please rate the level of Assistance for each of the activities of daily living (ADLs) described below:
Mobility*
How well can they get around? If in a wheelchair, can they propel on their own?
- 0 - Independent - able to get out of bed/chair and walk without help.
- 1 - Minimum Assistance - needs a little help getting out of bed or chair, unsteady when walking, may use walker or cane for balance or can propel own wheelchair.
- 2 - Moderate Assistance - requires hands-on help to get out of bed/chair, requires walker whenever walking or requires someone to push wheelchair at times.
- 3 - Total Assistance - cannot get out of bed without being lifted, no longer walks or cannot propel own wheelchair.
Time of day Mobility Assistance is needed:
- At all times
- Mornings
- Afternoons
- Evenings/bedtime
Mobility Comments:
Eating*
Can they feed themselves? Can they cut their meat?
- 0 - Independent - Uses utensils independently, including cutting own meat.
- 1 - Minimum Assistance - needs help cutting meat, holding beverage cup, can use utensils.
- 2 - Moderate Assistance - needs help using utensils, finger foods work well.
- 3 - Total Assistance - someone feeds the person.
Time of day when Feeding Assistance is needed:
- At all times
- Mornings
- Afternoons
- Evenings/bedtime
Feeding Comments:
Toileting*
Are there issues with getting to the bathroom on time? Are clothes/bed sheets stained with urine or feces?
- 0 - Independent - manages all needs without help.
- 1 - Minimum Assistance - needs help to toilet, wears incontinent product, occasionally needs to change clothes or bed linens due to an 'accident'.
- 2 - Moderate Assistance - frequently needs to change clothes/bed linens due to an 'accident', needs help changing incontinent product, occasionally able to have bowel movement or urinate in toilet.
- 3 - Total Assistance - unable to control bladder or bowels, does not use toilet.
Time of day when Toileting Assistance is needed:
- At all times
- Mornings
- Afternoons
- Evenings/bedtime
Toileting Comments:
Dressing*
Are their outfits appropriate for the season? Are the buttons closed appropriately? Clothes are not inside out?
- 0 - Independent - selects proper attire, dresses without help.
- 1 - Minimum Assistance - occasionally misbuttoned clothes, wears same clothes every day or occasionally wears clothes not appropriate for season.
- 2 - Moderate Assistance - usually wears clothes that are soiled, cannot select appropriate clothes, assistance needed to put clothes on/remove clothes.
- 3 - Total Assistance - unable to dress/undress self.
Time of day when Dressing Assistance is needed:
- At all times
- Mornings
- Afternoons
- Evenings/bedtime
Dressing Comments:
Bathing & Grooming*
Are there body odors? Are they taking showers or tub baths? Is hair washed and combed neatly? Are nails dirty?
- 0 - Independent - able to bathe and groom without help.
- 1 - Minimum Assistance - occasionally needs reminder to take shower/bath and/or hair is unkempt, forgets to shave.
- 2 - Moderate Assistance - usually looks unkempt, rarely bathes without assistance, refuses to bathe, bad breath odor.
- 3 - Total Assistance - unable to bathe or groom self.
Time of day when Bathing & Grooming Assistance is needed:
- At all times
- Mornings
- Afternoons
- Evenings/bedtime
Bathing & Grooming Comments:
Changes in Social Status
Mental Status
Additional Comments
Your Contact Information:
Your Name:*
First Last
Location:*
City ZIP / Postal Code
Email:*
Enter Email Confirm Email
Phone:*
Senior's Contact Information:
If you are completing this assessment for a senior, please provide their contact information.
Senior's Name:
First Last
Total Score:
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
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Families Choice Home Care | 545 N. Mountain Ave., Suite 209 | Upland, CA 91786 | 909-303-9377

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Living Well at Home Assessment

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

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

Your Contact Information:

Senior's Contact Information:

Evaluating Your Score: