Needs Assessment Worksheet

This worksheet will help you and other family members determine what types of assistance your loved one needs.
Activities Of Daily Living (ADLs)
Activity	Accomplishes alone	Needs some help	Needs much help	
Bathing				
Dressing				
Grooming				
Toileting				
Eating a nutritious diet				
Getting out of bed				
Getting out of chair				
Walking				
Instrumental Activities Of Daily Living (IADLs)
Activity	Accomplishes alone	Needs some help	Needs much help	
Using the telephone				
Shopping for personal items				
Transportation				
Managing money				
Doing laundry				
Doing light housework				
Preparing meals				
Conditions/Functional Status How do the following affect the person's ability to function?
Limitation	No effect	Some effect	Major effect	
Hearing 				
Vision				
Perception				
Orientation				
Thinking				
Memory				
Decision-Making/Judgment				
Physical Dexterity				
Balance				
Strength				
Energy				
Bladder or bowel control				
Arthritis				
Hypertension				
Heart disease				
Diabetes				
Physical deformity				
Depression				

Environmental Safety
Which barriers can be removed or changed?
Limitation	No Problem	Needs to be changed	
Neighborhood:			
Safety			
Convenience			
Friends or relatives nearby			
Living Quarters:			
Condition			
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 outside doors			
Peephole in front door			
Window bars or locks			
Visible from road (no large trees or bushes block view)			
Smoke alarms installed, tested			
Passageways clear of wires and clutter			
Stairs:			
Free of obstacles and clutter			
Well-lit			
Handrails on both sides			
In good repair and nonskid			
Clearly marked			
Floors:			
Nonskid level surfaces			
Nonglare surfaces			
No loose rugs			
Furnishings:			
Couch and chairs easy to use			
Tables the right height			
Bed easy to get in and out of			
Lighting:			
Light switches easy to reach			
Entries and walkways well-lit			
Reading areas well-lit			
Light diffused from windows and surfaces (no glare)			
Passageways have night lights			
Kitchen:			
Lever handles on sink			
Clean rubber mat by the sink			
Items used often are accessible			
Storage is easy to get to			
No objects are over the stove			
Well-lit			

Bathroom:			
Grab bars attached to studs, byt the toilet and tub or shower			
Nonskid strips in the tub or shower			
Hand-held shower head			
Nonslip bath mat or rug			

OTHER INFORMATION

List the 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 person uses, such as home-delivered meals or home chore services.

List services or support the 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.

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