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? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Drive or use public transportation on own? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Shop for groceries or clothing on own? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Prepare meals? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Take a bath or shower without help? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Get in and out of bed without help? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Be left alone during day? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Pay bills and manage finances on own? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Clean the house or apartment? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Manage household duties? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Live alone comfortably and confidently? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Remain active and interested in life and hobbies? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Maintain a positive attitude? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Walk, climb stairs and can get around the house easily? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Care about own personal health and well-being? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Manage own medications? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Maintain a healthy weight? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
Take care of themselves? |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/ckbx.gif) |
![](../../images/checklists/comments3.gif) |
For any question where you answered ?no? to any question, you should monitor that activity more closely or he/she may need additional care.