Resident Name

Date of Birth

Date of Assessment

Room Number

Assessor's Name

Assessor's Job Title

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 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 Assistance

• Independent

• Needs reminders or supervision

• Requires assistance

• Incontinent, needs regular support

Continence Products Used (if applicable)

• Pads

• Pull-ups

• Briefs

Level of Assistance Required

• Independent

• Needs encouragement or supervision

• Requires feeding assistance

Dietary Restrictions or Preferences

• Vegetarian

• Diabetic

• Low-sodium

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