Home Care Assessment Independent Living Assessment Activities of Daily Living · Safety · Cognition · Functional Capacity Subject Name Assessment Date Assessed By Yes — Can do independently Partial — With help/difficulty No — Unable to do N/A ⚑ Pre-filled based on known information 🧼 Basic Self-Care (ADLs) Personal hygiene, mobility, feeding Bathing or showering independently Yes Partial No N/A Dressing and undressing Yes Partial No N/A Grooming (hair, teeth, nails) Yes Partial No N/A Toileting independently Yes Partial No N/A Bladder/bowel continence Yes Partial No N/A Feeding herself adequate nutrition ⚑ Pre-filled Known: malnourished, eats insufficiently Yes Partial No N/A Walking/mobility without fatigue ⚑ Pre-filled Known: neuropathy in feet, limited walking, easy fatigue Yes Partial No N/A Getting in/out of bed or chair safely Yes Partial No N/A 🏠 Household & Life Management (IADLs) Higher-function independent living skills Driving or arranging own transportation ⚑ Pre-filled Known: cannot drive Yes Partial No N/A Preparing meals independently ⚑ Pre-filled Known: does not prepare meals regularly Yes Partial No N/A Managing finances (bills, banking) ⚑ Pre-filled Known: does not manage money independently Yes Partial No N/A Managing medications (correct dose/time) Yes Partial No N/A Indoor housekeeping (laundry, dishes, cleaning) Yes Partial No N/A Outdoor/yard maintenance ⚑ Pre-filled Known: cannot manage outside of home at all Yes Partial No N/A Grocery shopping independently Yes Partial No N/A Using phone or calling for help Yes Partial No N/A ⚠️ Safety Awareness Fall risk, hazard recognition, emergency response Recognizes fall risks and acts cautiously Yes Partial No N/A No falls in the past 6 months Answer "No" if she has fallen Yes Partial No N/A Safe kitchen habits (burners off, no fire risk) Yes Partial No N/A Can respond to emergency (fire, medical) Yes Partial No N/A Home is secure (locks doors, aware of surroundings) Yes Partial No N/A 🧠 Cognitive Function Memory, orientation, judgment Remembers recent events and appointments ⚑ Pre-filled Known: forgets things Yes Partial No N/A Oriented to day, date, and time Yes Partial No N/A Follows multi-step instructions Yes Partial No N/A Exercises good judgment and decision-making Yes Partial No N/A ❤️ Social & Emotional Wellbeing Isolation, mood, quality of life Maintains regular social contact Yes Partial No N/A No signs of depression or persistent low mood Yes Partial No N/A Engaged and purposeful during the day Yes Partial No N/A — Independence Score 0 Independent 0 Partial 0 Unable of 20 answered Calculate Assessment Score Reset All Answers
