Personal Independence Assessment
Evaluate your ability to perform daily living activities independently.
Full Name
*
First Name
Last Name
Age
*
Gender
Male
Female
Non-binary
Prefer not to say
Other
Contact Email
example@example.com
Please rate your level of independence in the following daily activities:
*
Rows
Independent
Needs Some Assistance
Requires Full Assistance
Personal hygiene (bathing, grooming)
1
2
3
Dressing
4
5
6
Feeding yourself
7
8
9
Toileting
10
11
12
Mobility (moving around home)
13
14
15
Medication management
16
17
18
How would you rate your communication skills (e.g., expressing needs, understanding others)?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How confident are you in managing your personal finances (e.g., paying bills, budgeting)?
*
Not at all confident
1
2
3
4
Very confident
5
1 is Not at all confident, 5 is Very confident
Do you use any assistive devices or aids to support your independence? (Select all that apply)
Wheelchair
Walker or cane
Hearing aid
Visual aid (e.g., glasses)
None
Other
Do you require regular support from another person to complete daily activities?
*
Yes
No
Please provide any additional comments or information about your independence or support needs.
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