Subjective (Reports)
Ability to carry out activities of daily living: Independent/dependent (level 1, no assistance needed, to level 4, completely dependent):
Mobility:_______________ Needs assistance (describe):_______________
Assistance provided by:_______________
Equipment/prosthetic devices required:_____________________________________________________________
Feeding:_______________ Needs assistance preparing/eating (describe):_______________
Assistive devices:_______________
Bathing:_______________________
Needs assistance setup/regulating water temp/washing body parts (describe):_______
Preferred time of personal care/bath:_______________________________________________________________
Dressing:_______________ Needs assistance selecting clothing/dressing self (describe):___________________
Toileting:_______________ Needs assistance transferring/cleaning self (describe):_________________________
Objective (Exhibits)
General appearance:_____________ Manner of dress:_____________ Grooming/personal habits:_____________
Condition of hair/scalp:__________________________________________________________________________
Body odor:_________________________ Presence of vermin (e.g., lice, scabies):__________________________
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