PCA Self Assessment

1

EatingEating includes hand washing and application of orthotics required for eating, transfers, and feeding/eating. The folowing questions are to determine whether you have a dependency in Eating.

2

Do you need help Eating?* This field is required.Do you have any difficulties with eating or require support or assistance with eating?

Yes

No

Sometimes

Choose not to answer

3

Do you need supervision Eating?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

4

Do you need physical assistance Eating?* This field is required.

None

Setup/Prep

Limited

Total Dependence

5

BathingBathing includes basic personal hygiene and skin care. The following quesitons are to determine if you have a dependency in Bathing.

Picture of Father Holding Child Wrapped in Bath Towel

6

Do you need help Bathing?* This field is required.Do you have any difficulties with bathing or require support or assistance during bathing?

Yes

No

Sometimes

Choose not to answer

7

Do you need supervision to Bath?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

8

Do you need physical assistance Bathing?* This field is required.

None

Setup/Prep

Limited

Total Dependence

9

DressingDressing includes choosing, application, and changing of clothing and application of special appliances, wraps, or clothing. The following quesitons are to determine if you have a dependency in Dressing.

Picture of Mother Putting Shoes on Adult Child with Disability

10

Do you need help Dressing?* This field is required.Do you have any difficulties with dressing or require support or assistance during dressing?

Yes

No

Sometimes

Choose not to answer

11

Do you need supervision Dressing?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

12

Do you need physical assistance Dressing?* This field is required.

None

Setup/Prep

Limited

Total Dependence

13

Personal Hygiene/Grooming Personal Hygine/Grooming includes basic hair care, oral care, shaving, nail care, applying cosmetics and deodorant, and care of eyeglasses and hearing aids. The following quesitons are to determine if you have a dependency in Personal Hygine/Grooming.

14

Do you need help with Personal Hygiene/Grooming?* This field is required.Do you have any difficulties with or require support or assistance to take care of your grooming and hygiene needs?

Yes

No

Sometimes

Choose not to answer

15

Do you need supervision to complete Personal Hygiene/Grooming?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

16

Do you need physical assistance with Personal Hygiene/Grooming?* This field is required.

None

Setup/Prep

Limited

Total Dependence

17

Toilet Use/Continence Support Bowel or bladder elimination and care including transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area, an inspection of the skin, and adjusting clothing. The following questions are to determine if you have a dependency in Toilet Use/Continence Support.

18

Do you need help with Toilet Use/Continence Support?* This field is required.Do you need assistance or support with toileting?

Yes

No

Sometimes

Choose not to answer

19

Do you need supervision while Toileting?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

20

Do you need Physical Assistance Toileting?* This field is required.

None

Setup/Prep

Limited

Total Dependence

21

Mobility – Walking and Wheeling Ambulation, including use of a adaptive equipment (Mobility does not include providing transportation for a consumer). The following quesitons are to determine if you have a dependency in Mobility.

22

Do you need help with Mobility?* This field is required.Do you have any difficulty with mobility or require support or assistance to get around?

Yes

No

Sometimes

Choose not to answer

23

Do you need supervision with Mobility?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

24

Do you need physical assistance with Mobility?* This field is required.

None

Setup/Prep

Limited

Total Dependence

25

PositioningPositioning or turning for necessary care and comfort. The following quesitons are to determine if you have a dependency in Positioning?

Caregiver Adjusting Pillow for Woman in Bed

26

Do you need help with Positioning?* This field is required.Does the person have any difficulties with positioning or require support or assistance when positioning?

Yes

No

Sometimes

Choose not to answer

27

Do you need supervision with Positioning?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

28

Do you need physical assistance with Positioning?* This field is required.

None

Setup/Prep

Limited

Extensive/Total Dependence

29

TransfersTransferring includes moving from one seating or reclining area to another; or moving from sitting to standing etc. The following quesitons are to determine if you have a dependency in Transferring.

30

Do you need help to Transfer?* This field is required.Does the person have any difficulties with transfers or require support or assistance when making transfers?

Yes

No

Sometimes

Choose not to answer

31

Do you need supervision to Transfer?* This field is required.

None

To start the task

Sometimes during the task

Constantly throughout the task

32

Do you need physical assistance to Transfer?* This field is required.

None

Setup/Prep

Limited

Total Dependence

33

Email for self assessment results* This field is required.Please enter your email to view your results.

example@example.com