Self-Care and Home Maintenance Assessment Form
Assess your ability to manage daily self-care and basic home maintenance tasks.
How would you rate your ability to perform daily self-care tasks (e.g., bathing, dressing, grooming) independently?
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1
2
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5
Which of the following self-care activities do you find challenging? (Select all that apply)
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Bathing or showering
Dressing
Grooming (hair, nails, etc.)
Toileting
Feeding yourself
None of the above
How often do you need assistance with preparing meals?
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Never
Occasionally
Frequently
Always
Rate your confidence in managing household cleaning tasks (e.g., vacuuming, dusting, laundry).
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2
3
4
5
Which home maintenance tasks do you need help with? (Select all that apply)
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Changing light bulbs
Taking out the trash
Basic repairs (e.g., fixing leaks)
Yard or outdoor maintenance
None of the above
How do you usually handle home safety checks (e.g., checking smoke alarms, securing doors/windows)?
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I do them independently
I need reminders
Someone assists me
They are not done regularly
How often do you experience difficulty moving safely around your home?
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Never
Rarely
Sometimes
Often
Select any challenges you face in managing bills or appointments.
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Remembering due dates
Paying bills on time
Scheduling appointments
None of the above
How do you usually obtain groceries and household supplies?
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Shop independently
With assistance
Delivery services
Family or friends help
Please describe any additional self-care or home maintenance needs or challenges you would like to share.
Submit Assessment
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