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Aging-in-Place Independence Assessment

Section 1 - Living Situation

1. Who is completing this assessment?
Myself (patient)
Parent/Family Member
Spouse
Client
Caregiver
2. What is the patients current living situation?
Lives with spouse/family
Lives alone (regular support)
Lives alone (minimal support)
Lives alone (no support)
3. Has the patient been hospitalized in the past 12 months?
No
Yes (only one time)
Yes (multiple times)

Section 2 - Fall Risk

4. Has the patient experienced any falls within the last 12 months?
No
Yes (one fall, no injury)
Yes (one fall, with injury)
Yes (two or more falls)
5. Does the patient often feel unsteady while walking?
No
Yes (occasionally)
Yes (frequently)
6. Does the patient utilize mobility devices?
No
Yes (cane)
Yes (walker)
Yes (wheelchair)
7. Does the patient ever had the fear of falling?
No
Yes (sometimes)
Yes (frequently)

Section 3 - Bathroom Safety

8. Do any of the following apply to patients current restroom?
9. Does the patient ever experience difficulty bathing?
No
Yes (mild)
Yes (moderate)
Yes (severe)
10. Does the patient ever experience nightime bathroom safety concerns?
No
Yes (sometimes)
Yes (frequently)

Section 4 - Daily Independence

11. Does the patient have difficulty performing daily activities? Check all that apply.
12. Has the patient experienced a change in indepence over the last year?
No decline
Slight decline
Moderate decline
Significant decline

Section 5 - Home Environment

13. Does the patient have any home environment hazards? Check all that apply.

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