Assessment – Care Form Solutions

CLIENT		DATE

	YES	NO
Do you need help cleaning your house?	YES	NO
If yes; do you need help with:
Cleaning the Kitchen?	YES	NO
Sweeping and mopping floors?	YES	NO
Washing dishes?	YES	NO
Drying dishes?	YES	NO
Cleaning counter tops?	YES	NO
Cleaning the oven?	YES	NO
Gathering and taking out trash? Note day trash is picked up.
Cleaning the Living area	YES	NO
Vacuum the floor	YES	NO
Dusting the furniture?	YES	NO
Cleaning the Bedroom	YES	NO
Make the bed?	YES	NO
Vacuum the floor?	YES	NO
Dusting the furniture?	YES	NO
Change the sheets?	YES	NO
Cleaning the Bathroom	YES	NO
Cleaning bathroom floors and walls?	YES	NO
Cleaning sink, tub, toilet?	YES	NO

	YES	NO
Do you need help grocery shopping?	YES	NO
If yes;
Do you want your CAREGIVER to do your grocery shopping for you?	YES	NO
Do you need your CAREGIVER to write the grocery list?	YES	NO
Do you need your CAREGIVER to go with you to the grocery store?	YES	NO
Do you need help putting groceries away?	YES	NO
Do you need your CAREGIVER to clip coupons?	YES	NO
Do you need help to pay at the register?	YES	NO
Do you use or would you like to use adaptive equipment to help you shop?	YES	NO
Errands and appointments:
Do you use public transportation?	YES	NO
If no:
Will you need transportation for any of the following:
• Doctor appointments	YES	NO
• Dentist appointments	YES	NO
• Therapist appointments	YES	NO
If you have an adapted vehicle, does it have:
• a lift	YES	NO
• hand controls	YES	NO
• foot controls	YES	NO
• adapted steering wheel	YES	NO
Will you need someone to drive your vehicle to appointments? Do you	YES	NO
need help scheduling or canceling appointments?	YES	NO
Do you need help transferring in and out of the car? Do	YES	NO
you need physical help getting into a building? Do you need	YES	NO
help once you are inside a building? Do you use a service dog?	YES	NO
Do you need your CAREGIVER to give you verbal cues?	YES	NO
Other Considerations: Please explain any kind of help you need in order to access your community:

	YES	NO
Do you need help doing laundry?	YES	NO
If yes;
Do you need your CAREGIVER to do the laundry for you?	YES	NO
Do you need help sorting your laundry?	YES	NO
Do you need help washing/drying your laundry?	YES	NO
Do you need help folding your laundry?	YES	NO
Do you need help putting your laundry away?	YES	NO
Do you need help with ironing?	YES	NO
Do you need any items hand washed?	YES	NO
Do you need any clothes taken to the dry cleaner?	YES	NO

	YES	NO
Do you need help preparing meals?	YES	NO
If yes;
Will you plan your meals?	YES	NO
Do you want help planning your meals?	YES	NO
Do you need your CAREGIVER to prepare all your meals for you?	YES	NO
Do you want your CAREGIVER to prepare meals and put them in the refrigerator or freezer for later use?	YES	NO
Do you need help eating?	YES	NO
Do you need help cutting your food?	YES	NO
Do you need your homecare worker to feed you?	YES	NO
Do you need your CAREGIVER to position your glass, plate and utensils?	YES	NO
Do you need stand-by assistance in case of choking?	YES	NO
Are you on a special diet?	YES	NO
Do you use adaptive equipment to feed yourself?	YES	NO
For example: • Utensil with an adapted handle • Weighted utensil • Rocker knife • Rimmed plate • Flexible straw • Tube feeding machine
Other Considerations:
Special diet (diabetic, allergies)

	YES	NO
Do you need help bathing?	YES	NO
If yes;
Do you bathe every day?	YES	NO
Do you use the shower?	YES	NO
Do you use the bathtub?	YES	NO
Do you prefer a bed bath?	YES	NO
Do you need help washing your body?	YES	NO
Do you wash any parts of your body by yourself?	YES	NO
Do you need help with skin care treatments?	YES	NO
Do you need help transferring?	YES	NO
Do you need help washing your hair?	YES	NO
Do you need help drying your body?	YES	NO
Do you need help drying your hair?	YES	NO
Do you need help combing your hair?	YES	NO
Do you need help with deodorant or cologne?	YES	NO
Do you use or would you like to use AT devices or durable medical equipment (DME)? For example:	YES	NO
• Grab bars • Bath bench • Shower chair • Extended back brush • Extended handle wash mitt
Other Considerations:

	YES	NO
Do you need help brushing your teeth?	YES	NO
If yes;
Do you brush you teeth 1x, 2x or 3x a day	YES	NO
Other, please explain:
Do you use an electric toothbrush?	YES	NO
Do you need help with your electric toothbrush?	YES	NO
Do you have removable dentures or other removable dental device?	YES	NO
Do you need help removing dentures or other dental device? Do you need help cleaning dentures or other dental device? Do you have gum disease?	YES	NO
Please explain service needed:
Other Considerations:
Do you need help getting dressed?	YES	NO
Do you need help getting undressed?	YES	NO

	YES	NO
Do you go to therapy?	YES	NO
Number of times per week
Do you want your CAREGIVER to be trained to help you with exercises/stretches?
Other Considerations:
TRANSFERRING
Do you need help with transferring? Do you use any special equipment to transfer? (transfer board, hydraulic or electric lift)
Please mark the areas you need help in transferring to or from: Bed Toilet Chair Car Bath/Shower
Other, please explain:

Think about:	YES	NO
We are non-medical and CANNOT ADMINISTER medication, we can ONLY REMIND you to take your medication.
Do you need help with toileting?	YES	NO
If yes;
Are you on a bladder care program?	YES	NO
Do you need assistance with your bladder program?	YES	NO
Do you have urgency?	YES	NO
Do you use a catheter?	YES	NO
Do you use a urinal?	YES	NO
Do you use a leg bag?	YES	NO
Are you on a bowel care program?	YES	NO
Do you need assistance with your bowel program?	YES	NO
Do you have an ostomy?	YES	NO
Give as much detail as possible, for example, transfer help, anything invasive, and help with cleaning.
Do you need help removing clothing?	YES	NO
Do you need help cleaning after toileting?	YES	NO
Do you need help transferring to or from the toilet?	YES	NO
Do you use adult incontinence products? Please explain help needed: (for example, removing briefs, cleaning, replacing briefs)	YES	NO
Do you use the toilet?	YES	NO
Do you use grab bars	YES	NO
Do you need help to get up or down from the toilet or commode?	YES	NO
Do you use a bedside commode?	YES	NO
Do you empty the bedside commode?	YES	NO
Do you use a bedpan?	YES	NO
Other Considerations:

Think about:	YES	NO
Are you able to express yourself verbally and be clearly understood by others?	YES	NO
Do you understand what people are saying to you?	YES	NO
If no;
Do you use sign language?	YES	NO
Do you read sign language?	YES	NO
Do you use gestures with some speech?	YES	NO
Do you use a communication device?	YES	NO
Do you use hearing aids?	YES	NO
Do you need someone to clean and check the batteries of your hearing aids?	YES	NO
Other Considerations:

	YES	NO
Do you have any pets?	YES	NO
THIS MAY BE CHANGED WHENEVER A CHANGE IN JOB DUTIES IS NEEDED.

Authorized Signature:

Date:

TRANSFERRING