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CARE WORLD HOME CARE ASSESSMENT FORM

DIRECTIONS:
This checklist is intended to identify areas of concern that you may want to monitor more closely or gather more information about.

Live alone? Yes No

CAREGIVER NEED:

PERSONAL CARE

Bed Bath
Partial Bath
Shower
Tub Bath
Oral Hygiene / Denture Care
Shampoo
Comb / Brush / Dry Hair

TOILETING

Uses Bathroom
Uses Bedpan
Urinal
Diapers / Depends
Night Time Care

SLEEPING PATTERN:

HOMEMAKING

Meal Preps:

Breakfast
Lunch
Dinner
Snack
Dishes

HOUSEKEEPING

Linen Change
Light Laundry
Kitchen Upkeep
Bathroom
Bedroom

TREATMENTS

Temperature
Blood Pressure
Catheter
Ostomy Bag

ACTIVITIES

Up as Tolerated
Transfer Board
Hoyer Lift

Ambulation

With Full Assist
Cane
Crutches
Walker
Wheel Chair

Bedrest

Complete w/ Toilet Privileges
Complete w/o Toilet Privileges
Turn & Reposition
Use Commode Chair
Bed / Fracture Pan

Exercises

Range of Motion as taught by RN/PT
Active ROM
Passive ROM