Capable of moving about independently. Able to seek and follow directions. Able to evacuate independently in case of emergency. (1 point)
Ambulatory with cane or walker. Independent with wheelchair but needs help in emergencies. (3 points)
Requires occasional assistance to move about, but usually independent. (4 points)
Mobile, but may require assistance due to confusion, poor vision, weakness, or poor motivation. (6 points)
May require assistance when transferring from bed, chair, or toilet. (7 points)
Requires transfer and transport assistance. Requires turning in bed and in wheelchair. (10 points)
Able to prepare own meals. Eats meals without assistance. (1 point)
Can do some meal preparation, but needs main meal prepared daily. (4 points)
Needs all meals prepared and served. (6 points)
May require assistance when eating, such as opening cartons or cutting food. (8 points)
Mostly or totally dependent on others for nourishment, includes reminders to eat. (10 points)
Independint in all care including bathing, shaving, dressing. (1 point)
May require assistance bathing or hygiene, reminders, or initiation assistance. (4 points)
Dependent on others for most or all personal hygiene tasks. (6 points)
Independent in performing housekeeping functions such as bed making, vacuuming, cleaning, and laundry. (1 point)
May need assistance with heavy housekeeping, vacuuming, laundry, changing linens. (4 points)
Needs laundry and housekeeping services provided. (6 points)
Independent and dresses appropriately. (1 point)
May require assistance with shoelaces, zippers, medical appliances, or garments. May require reminders, motivation, or initiation assistance. (6 points)
Dependent on others for dressing. (10 points)
Independent and completely continent. (1 point)
May have incontinence, a colostomy or catheter, but is independent in caring for self. (3 points)
May have incontinence, a colostomy or catheter, but requires assistance in caring for self. (5 points)
May be unwilling or unable to manage own incontinence through proper use of supplies or requires physical assistance with toileting on a regular basis. (8 points)
Regularly and uncontrollably incontinent, dependent or unable to communicate needs. (10 points)
Responsible for self-administration of medications. (1 point)
Able to self-administer medications, but others may need to remind and monitor the actual process. (5 points)
Requires medication administration system with reminders and monitoring by family members or others. (8 points)
Cannot administer own medications, even with supervision. Medications must be administered by licensed personnel. (12 points)
Oriented to person, place, and time. Memory is intact but may have occasional forgetfulness with no pattern of memory loss. Able to reason, plan, and organize daily events. Has mental capacity to identify environmental needs and meet them. (2 points)
May require occasional direction or guidance in getting from place to place, or may have difficulty with occasional confusion that results in anxiety, social withdrawal, or depression. Orientation to time, place, or person may be minimally impaired. (5 points)
Judgment may be poor. May not attempt tasks that are not within capabilities. May require strong orientation assistance and reminders. (10 points)
Disoriented to time, place, and person, or memory is severely impaired. Often unable to follow direction. (15 points)
Deals appropriately with emotions and uses available resources to cope with inner stress. Deals appropriately with others. (1 point)
May require periodic intervention from others to facilitate expression of feelings in order to cope with inner stress. May require periodic intervention from others to resolve conflicts and cope with stress. (2 points)
May require regular intervention from others to facilitate expression of feelings and to deal with periodic outbursts of anxiety or agitation. (8 points)
Maximum intervention is required to manage behavior. May pose physical danger to self or others. Is abusive or unacceptably uncooperative. (20 points)
Do you want to remain at home or move into a community with other people?
I would like to remain at home.
I would be willing to move into a community with others.
Are you lonely? Would you like to have people to do things with?
Are there people or places you would like to live close to?
What is your monthly budget?
What services are you entitled to through your insurance?