Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
IN OUT
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Total 0.0
Checklist of Activities of Daily Living (ADL)
Client Name
*
First Name
Last Name
Check the level of function of each activity of daily living listed below. This will help you determine how much assistance an elder needs.
*
INDEPENDENT
NEEDS HELP
DEPENDENT
DOES NOT DO
Personal Care
Incontinence Care
Bowel movement/elimination
Reposition (bedsore prevention)
Sleeping pattern
Meal planning/Assistance
Transfer assistance
Medication log
Physical activities
Social activities
Behavior/Mental Condition
Visitors/Guests
Light housekeeping
Correspondence
Vital signs
Driving
GENERAL NOTES/ADDITIONAL COMMENTS
*
(new or discontinued medications, low supplies, upcoming appointment, change of condition, etc.)
Signature
*
Submit
Submit
Name
*
First Name
Last Name
Should be Empty: