Activities of Daily Living Assessment Questions

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Your Name *

Phone number

My medical history - I have the following conditions *

Who do you live with? What are their ages? *

What do you do/Go on Mondays?

What do you do?/Go on Tuesdays

What do you do?/Go on Wednesdays?

What do you do?/Go on Thursdays?

What do you do?/Go on Fridays?

What do you do?/Go on Saturdays?

What do you do?/Go on Sundays

Routines: How often and when do you shower? please tick all that apply

Daily at night

Daily in the mornings

every second day at night

Every second day in the morning

3 times a week at night

3 times a week in the mornings

twice a week

weekly

less often than weekly

when ever - no set days or times

Do you need help in the shower or reminders? tick all that apply *

reminders to have one

reminders to get clothes out

Reminders/prompts to wash all my body

Help to get my clothes/towel ready

Help to turn on the taps and get the temperature right

reminders to wash hair

Help to wash hair

Help to get in and out of the shower

I need to sit down

I hold rails

Help to wash my body - back/buttocks

help to wash my body - front

help to wash my body - legs/feet

Help to wash my body everywhere

I can do all parts of showering with no help or prompting

Required

Do you need help or prompting with Dressing: Tick all that apply

Prompting on what clothes to select appropriate to the weather and occasion

Help to select clothes appropriate to the weather and occasion

I need to sit down to dress

Help to put on upper body clothes such as tshirts, jumpers, shirts, cardigans, dresses

help to put on lower leg clothes such as trousers, underwear, skirts

Prompting or help on the order to get dressed eg underwear before trousers

Help with shoes and socks

help with doing up buttons and zips

I need assistance with all areas listed above

I do not need any help or prompting with dressing

I brush my teeth...Tick all that apply

Daily - Morning and night

Daily in the mornings

Daily in the evenings

Every second day

a few times per week

once a week

once every 2 weeks

Rarely

once a month

I have trouble remembering

I need reminding

I have trouble operating the toothbrush

Make - up - Tick all that apply

I don't wear make up

I wear make up and I can do it without issues

I wear make up however find it tricky

I need help

Shaving - Tick all that apply

I can shave myself with no help or reminding

I need a reminder to shave

I need ALOT of reminders to shave

I need help to set up to shave but can do it myself

I need help with all parts of shaving

I use an electric shaver

Going to the toilet Tick all that apply

I have no issues with going to the toilet at all

Bladder - I need to be reminded to go

I need help to get to the toilet physically

It is tricky to get on and off the toilet

I have accidents with urine

I have accidents with bowels

I use continence aids

I need full help with toiletting

Medication - Tick all that apply

I manage my own medication and have no problems remembering

I need reminding to take my medication

I need full help with my medication

I have a webster pack

I dont take medication

What approximately time do you go to bed?

Time

How long does it take for you to fall asleep

Do you have difficulties getting in out of bed? Tick all that apply

Yes - I need help but dont have any

Yes I have help but it is still hard

No I can manage with help

No I can manage without help

Clear selection

Walking - I have the following mobility aids to help me walk Tick all that apply

I dont have any aides

I have no difficulties walking

Single stick

crutches

Four wheel walker with seat

wheelchair - electric

Wheelchair - manual

Scooter

have you had any falls? If yes, explain below

Cooking and meal preparation -Tick all that apply

I prepare all my own meals without help or reminding

I make my own breakfast

I make my own lunch

I make my own dinner/tea

I help prepare some meals

I make my own drink

I can get may own snack

I can. use a sandwich maker

I can use a toaster

I can operate a oven and stove top

I need supervision while I am in the kitchen

I need reminding to do certain tasks in when preparing a meal

I can follow a recipe with out help

I can follow a recipe with help

I can follow a recipe without help if I have pictures

I can grate

I can chop/slice

I can peel vegetables

I get tired and/or pain when standing in the kitchen

I need all my meals prepared for me

Cleaning - Tick all that apply

I am able to clean my home without help or reminding

I need help to clean my home

I can put on a load of washing without help

I can hang a load of washing without help

I can do part of washing the dishes such as washing up, drying up, putting away

I can do all parts of washing the dishes

I can hang the washing

I can fold and put away washing

I can do the cleaning tasks with help

I can clean the bathroom

I can clean the toilet

I can vacuum

I can mop

I can take out the rubbish to the outside bin

I can sweep

I can make my bed

I change my sheets on my bed

I can wipe benches down and put away items

Shopping - Tick all that apply

I am independent in grocery shopping

I can make a shopping list

I can remember to bring my shopping list

I can collect times off the shelves and place them in the trolley

I can select the products that are the best value for money

I can select products that are considered healthy

I can unpack the trolley at the checkout

I can remain in the supermarket for the time required

I can pay at the checkout

I can check if I have the correct change

Do you have a mobile phone? -Tick all that apply

No I would have trouble being able to use it

No I would call it alot

No I would need help to use it

Yes and I can text on it

yes and I can make a call on it

Yes and I can answer calls

yes and I can use social media or other apps on it

Money -Tick all that apply

I recognise coins/notes

I understand money

I. can work out if I have enough money

I need help working out how much money to pay with

I can pay with a card using "paypass"

I can pay with a card by typing in my pin number

I can get money out of an ATM machine

I have a budget

My money is managed by public trustees

My money is managed by a family member

I pay my own bills and manage my own money

Friends- please list some friends names

What are some hobbies and interests you enjoy?

Do you have difficulties with your memory?

Yes

Maybe

Clear selection

Behaviours - please describe an behaviours of concern

What are you most wanting to discuss with Kelly? *

Submit

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