Needs Assessment Worksheet - Caregivers Library

Needs Assessm ent Wo rksheet

This w orksheet w ill help y ou a nd other fa m ily m em bers d eterm ine w ha t ty p es of a ssista nce y our lov ed one need s.

Activities Of Daily Living ( ADLs)

Act iv it y Bat h in g Dr essi n g Groom ing Toilet ing Eat ing a nut rit ious diet Get t ing out of bed Get t ing out of chair Walking

Accom plishes alone

Needs som e help

N eeds m uch help

I nstrum ental Activities Of Daily Living ( I ADLs)

Act iv it y Using t he t elephone Shopping for personal item s Transport at ion Managing m oney Doing laundry Doing light housework Preparing m eals

Accom plishes alone

Needs som e help

N eeds m uch help

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Condit ions/ Funct iona l St a t us

How do the following affect the person's ability to function?

Lim itation Hearing Vision Percept ion Orient at ion Th i n k i n g Mem ory Decision- Making/ Judgm ent Physical Dext erit y Balance St r en g t h En er g y Bladder or bowel control Ar t h r it is Hy per t en sion Heart disease Diabet es Physical deform it y Dep r essi on

No effect

Som e effect

Major effect

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Environm ent al Safet y

Which barriers can be removed or changed?

Lim itation

No Problem

Neighborhood:

Saf et y

Co n v en i en ce

Friends or relat ives nearby

Living Quarters:

Condit ion

Age of dwelling

Roof in good repair

Windows in good repair

Siding in good condition

Looks cared for

Security and safety

Dead bolt locks on out side doors

Peephole in front door

Window bars or locks

Visible from road ( no large t rees or bushes block view)

Sm oke alarm s installed, tested

Passageways clear of wires and clut t er

St a ir s:

Free of obst acles and clut t er

Well- lit

Handrails on both sides

I n good repair and nonskid

Clearly m arked

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Needs to be changed

Fl o o r s: Nonskid level surfaces Nonglare surfaces No loose rugs Fu r n ish in g s: Couch and chairs easy t o use Tables t he right height Bed easy to get in and out of Lig h t in g : Light swit ches easy t o reach Ent ries and walkways well- lit Reading areas well- lit Light diffused from windows and surfaces ( no glare) Passageways have night light s Kit ch e n : Lever handles on sink Clean rubber m at by t he sink I tem s used often are accessible Storage is easy to get to No obj ects are over the stove Well- lit Bathroom : Grab bars at t ached t o st uds, byt t he t oilet and t ub or shower Nonskid strips in the tub or shower Hand- held shower head Nonslip bath m at or rug

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OTHER INFORMATION List the older person's informal support networks, such as a neighbor who runs errands or a youth who shovels snow and chops wood. List social services the older adult uses, such as home-delivered meals or home chore services. List services or support the older person says he or she needs or wants. List your needs as a caregiver.

? What obligation compete for your time and resources? ? How can you maintain your physical, mental, social, and financial well-being? List services or support you use as a caregiver to help provide care.

? Co p yrigh t Fam ilyCare Am e r ica , In c. All Righ ts Re s e rve d . Ad ap te d fro m "Eld e r Ca r e Ch o ice s a n d D e cis io n s : Lo ca t in g Co m m u n it y R e s o u r ce s ," B3 6 0 3 -2 , p ro d u ce d by th e U n ive rs ity o f W is co n s in -Exte n s io n Co o pe rative Exte n s io n Se rvice s in co n ju n ctio n w ith th e Un ite d State s De partm e n t o f Agricu ltu re .

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