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Self Assessment
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Section 1: Personal Care
Can the person bathe or shower?
*
Yes, independently
Needs some help
Needs full help
Can the person dress without help?
*
Yes, independently
Needs some help
Needs full help
Can the person manage grooming (hair, teeth, nails)?
*
Yes, independently
Needs some help
Needs full help
Can the person use the toilet independently?
*
Yes, independently
Needs some help
Needs full help
Section 2: Mobility & Transfers
Can the person walk safely inside the home?
*
Yes, independently
Needs some help
Needs full assistance
Can they get in and out of bed/chair?
*
Yes, independently
Needs some help
Needs full assistance
Does the person have a fall risk?
*
No
Moderate
High
Section 3: Meals & Nutrition
Can they grocery shop?
*
Yes
Some help needed
Cannot do it
Can they prepare their meals?
*
Yes
Some help needed
Full help needed
Do they forget to eat or skip meals?
*
No
Sometimes
Often
Section 4: Medication Management
Do they take medications as scheduled?
*
Yes
Sometimes
No
Do they understand their medication instructions?
*
Yes
Somewhat
No
Do they need help refilling prescriptions?
*
No
Occasionally
Yes
Section 5: Memory & Supervision
Do they forget names, places, or dates?
*
No
Sometimes
Frequently
Do they become disoriented or wander?
*
Never
Occasionally
Often
need the the
Do they get anxious or unsafe when alone?
*
No
Sometimes
Yes
Section 6: Home Support
Can they do housekeeping or laundry?
*
Yes
Some help needed
Full help needed
Can they manage mail and bills?
*
Yes
Needs reminders
Full help needed
Can they use a phone or emergency alert?
*
Yes
With help
Not at all
Total Score
Care Recommendation
Minimal care needed (2–3 hours/day)
Moderate care needs (4–6 hours/day)
High needs (8–10 hours/day)
Full-time care or live-in care strongly recommended (12–24 hours/day)
Contact Information
Name
*
First
Last
Email
*
Phone
*
Preferred Contact Method
*
Phone
Email
Would you like to schedule a consultation?
*
Yes
No
Preferred Date and Time
*
Date
Time
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