ADL Care Needs Self-Assessment (6 Questions)

1. How much assistance do you need with personal care (bathing, dressing, grooming)?
A. None — I’m fully independent
B. Occasional reminders or minimal help
C. Regular hands-on assistance needed
D. Full assistance required

2. How well are you able to manage mobility (walking, transferring, stairs)?
A. Fully independent, no difficulty
B. Mild difficulty, may use a device (cane/walker)
C. Need assistance from another person at times
D. Unable to move safely without full support

3. How do you manage medications and health needs?
A. Completely independent
B. Need reminders or occasional help
C. Require regular assistance to manage properly
D. Cannot manage without full supervision or nursing care

4. How would you describe your cognitive function (memory, decision-making)?
A. No issues
B. Mild forgetfulness
C. Frequent confusion or difficulty making decisions
D. Significant impairment affecting safety

5. How well are you managing household tasks (cooking, cleaning, finances)?
A. Fully independent
B. Need occasional help
C. Unable to manage most tasks
D. Completely dependent on others

6. Have you experienced any recent health changes or safety concerns (falls, hospitalizations)?
A. No recent concerns
B. Minor issues, no major impact
C. Recent decline or increased safety concerns
D. Frequent incidents or serious medical needs

Scoring & Recommended Level of Care

• Mostly A’s:
  Independent Living
  → No formal care needed; may benefit from community resources or wellness check-ins
• Mostly B’s:
  Home Care (Non-Medical Support)
  → Occasional caregiver help (companionship, light housekeeping, reminders)
• Mostly C’s:
  Assisted Living or Regular In-Home Care
  → Daily assistance with ADLs; structured support environment recommended
• Mostly D’s:
  Skilled Nursing Facility or High-Level Medical Care
  → 24/7 supervision and medical support likely needed

Important Note

This tool is a general guideline and not a clinical assessment. A licensed healthcare provider should complete a full evaluation before making care decisions.