Free Nursing Home Personal Care Assessment Form

Please complete this form to help us understand the personal care needs and preferences of our residents.
Resident Information
Resident Name
Date of Birth
Date of Assessment
Room Number
Assessor's Name
Assessor's Job Title
Daily Hygiene Needs
Assistance Required
Check all that apply:
Bathing/Showering
Oral Care (brushing teeth, dentures)
Hair Care (washing, brushing, styling)
Shaving
Nail Care (fingernails and toenails)
Dressing/Undressing
Frequency of Assistance
Check all that apply:
Daily
Every other day
Weekly
As needed
Mobility and Transfer Needs
Mobility Level
Select the number that best represents the mobility level (0 = Requires Full Assistance, 10 = Independent)
Transfer Requirements
No Assistance
Minimal Assistance (e.g., guidance, supervision)
Moderate Assistance (e.g., one-person lift)
Full Assistance (e.g., two-person lift, hoist)
Toileting and Continence Care
Toileting Assistance
Independent
Needs reminders or supervision
Requires assistance
Incontinent, needs regular support
Continence Products Used (if applicable)
Pads
Pull-ups
Briefs
Eating and Nutrition Needs
Level of Assistance Required
Independent
Needs encouragement or supervision
Requires feeding assistance
Dietary Restrictions or Preferences
Vegetarian
Diabetic
Low-sodium
Other Personal Care Needs
Sleep and Rest Patterns
Independent
Requires assistance with positioning
Other specific needs
Communication Needs
No assistance required
Hearing aid
Vision aid (e.g., glasses)
Additional Information
Provide any additional comments, notes, etc.
Please check the box below to proceed
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