Independent Living Assessment Survey

As we age, it is natural to want to continue living independently for as long as possible. However, sometimes changing needs and abilities require additional assistance in order to remain safely in the comfort and familiarity of home.

Complete this brief questionnaire to determine whether now might be the right time to consider in-home care for your loved one in order to help them enjoy a vibrant and independent lifestyle.

During the past few months, have you observed that your loved one is needing increased assistance with or reminders for:
	Yes	No
Getting in and out of bed?	Getting in and out of bed?: *
Navigating stairs and moving around the house?	Navigating stairs and moving around the house?: *
Bathing and dressing?	Bathing and dressing?: *
Personal grooming and hygiene?	Personal grooming and hygiene?: *
Preparing meals?	Preparing meals? : *
Stocking the kitchen with nutritious foods?	Stocking the kitchen with nutritious foods?: *
Eating regular, balanced meals?	Eating regular, balanced meals?: *
Taking medications as prescribed?	Taking medications as prescribed?: *
Engaging in physical activity?	Engaging in physical activity?: *
Performing household chores?	Performing household chores?: *
Doing laundry?	Doing laundry?: *
Sorting mail and paying bills?	Sorting mail and paying bills?: *
Communicating with others?	Communicating with others?: *
Engaging in recreational or social activities?	Engaging in recreational or social activities?: *