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AGING INFORMATION NETWORK
ASSESSMENT FORM
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CAREGIVER/DEGREE OF SUPPORT
*High degree of support: a high level of primary
caregiver/informal support is either given or is available from family and friends.
*Usually sufficient support: support or potential support from primary and/or informal support; if usually sufficient for present level of care
but occasional relief (e.g. respite) might be needed.
*Problematic: based on the present level of care receiver needs; primary/informal support is available but changing, fragile, or otherwise problematic.
DEFINITIONS
*Excellent (Need No Assistance)
*Good (Perform well with little help)
*Fair (Regularly requires help)
*Poor (Need help daily)
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1) RE-ENTER YOUR FULL NAME
_____________________________________________
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2) PHYSICAL HEALTH
* Excellent
* Good
* Fair (Moderately)
* Poor (Severely Impaired)
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3) FUNCTIONAL ABILITY (Activities of Daily Living)
* Excellent
* Good
* Moderately
* Severely
* Completely Impaired
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4) MOBILITY (Walking Indoors)
* Independent
* Assistive Device and/or with Difficulty
* Minimum Assistance with some hands for support
* Maximum Assistance Necessary
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5) INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
*Examples: bathing, dressing, eating, preparing foods, writing, etc.*
* Excellent
* Good
* Moderately
* Severely
* Totally Impaired
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6) COGNITIVE FUNCTIONING/MENTAL HEALTH
* Intact
* Substantially Intact
* Personal Supervision Needed
* Frequent Supervision
* Constant Supervision
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7) EMOTIONAL BEHAVIOR
* Above Average
* Average
* Moderately (alleged or apparent)
* Serious (alleged or apparent)
* Severe (alleged or apparent)
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8a) ANY PAST PSYCHIATRIC HOSPITALIZATIONS?
* Yes
* No
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8b) WHEN?
* Never
* 1 month or less
* 2 months or more
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9) PLEASE LIST ALL MEDICATIONS BELOW
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10) DOES CLIENT REQUIRES SKILL CARE? EXPLAIN
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