Activities of Daily Living Assessment Questions
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
Do you need help in the shower or reminders? tick all that apply *
Do you need help or prompting with Dressing: Tick all that apply
I brush my teeth...Tick all that apply
Make - up - Tick all that apply
Shaving - Tick all that apply
Going to the toilet Tick all that apply
Medication - Tick all that apply
What approximately time do you go to bed?
How long does it take for you to fall asleep
Do you have difficulties getting in out of bed? Tick all that apply
Clear selection
Walking - I have the following mobility aids to help me walk Tick all that apply
have you had any falls? If yes, explain below
Cooking and meal preparation -Tick all that apply
Cleaning - Tick all that apply
Shopping - Tick all that apply
Do you have a mobile phone? -Tick all that apply
Money -Tick all that apply
Friends- please list some friends names
What are some hobbies and interests you enjoy?
Do you have difficulties with your memory?
Clear selection
Behaviours - please describe an behaviours of concern
What are you most wanting to discuss with Kelly? *
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