Assessing Your Loved One Checklist | By Your Side Home Care

Name*

Email*

Phone*

Task/Activity

Level of Help Needed

None

Some

A Lot

Bathing:

Sponge Bath

None
Some
A Lot

Shower

None
Some
A Lot

Full Bath

None
Some
A Lot

Dressing (putting on clothes)

None
Some
A Lot

Grooming (hair, shave, teeth)

None
Some
A Lot

Assistance with Walking (a person must help):

Uses Walker

None
Some
A Lot

Uses Wheelchair

None
Some
A Lot

Uses Cane

None
Some
A Lot

Getting in and out of bed/chair

None
Some
A Lot

Assistance with going to toilet

None
Some
A Lot

Incontinence Care (adult briefs, catheter)

None
Some
A Lot

Meal Preparation:

Arrange food on a place, cut food

None
Some
A Lot

Place food in mouth

None
Some
A Lot

Other:

Medication Reminders (remind of times to take pills)

None
Some
A Lot

Medication Organization (sort/place pills in dispenser)

Not Applicable

Socializing (how much are they interacting w/ others)

None
Some
A Lot

Shopping (groceries, clothes)

None
Some
A Lot

Light Housekeeping

None
Some
A Lot

Doing Laundry

None
Some
A Lot

Handling the mail

None
Some
A Lot

Scheduling Doctor's Appointments

None
Some
A Lot

Providing Transportation (driving)

None
Some
A Lot

Managing Medications (order refills)

None
Some
A Lot

Managing Money (pay bills)

Not Applicable

Handling Household Chores (garbage, repairs)

None
Some
A Lot

Handing Health Insurance Matters

None
Some
A Lot

Number of Hours can be left alone

CAPTCHA

Homecare needs

assessment