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 *
Required
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?
Time
:
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? *
Submit
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