Directions: This checklist is intended to identify areas of concern that you may want to monitor more closely or gather more information about.
| Can your relative… |
Yes |
No |
Comments |
| Dress and undress without help? |
 |
|
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| Drive or use public transportation on own? |
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|
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| Shop for groceries or clothing on own? |
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|
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| Prepare meals? |
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|
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| Take a bath or shower without help? |
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| Get in and out of bed without help? |
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|
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| Be left alone during day? |
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|
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| Pay bills and manage finances on own? |
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|
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| Clean the house or apartment? |
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| Manage household duties? |
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| Live alone comfortably and confidently? |
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| Remain active and interested in life and hobbies? |
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| Maintain a positive attitude? |
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| Walk, climb stairs and can get around the house easily? |
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| Care about own personal health and well-being? |
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| Manage own medications? |
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| Maintain a healthy weight? |
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| Take care of themselves? |
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For any question where you answered ?no? to any question, you should monitor that activity more closely or he/she may need additional care.
