Elderly Independent Living Assessment Questionnaire Form
A concise assessment to evaluate key aspects of independent living ability. Please answer each question to the best of your knowledge.
Full Name
*
First Name
Last Name
Current Living Arrangement
*
Lives alone
With spouse/partner
With family
Assisted living facility
Other
Rate the individual's ability to perform the following activities independently:
*
Rows
Independent
Needs some assistance
Requires full assistance
Personal hygiene (bathing, grooming)
1
2
3
Meal preparation
4
5
6
Household tasks (cleaning, laundry)
7
8
9
Mobility (walking, transferring)
10
11
12
Medication management
13
14
15
How confident are you in the individual's ability to manage daily tasks independently?
*
1
2
3
4
5
Does the individual have any difficulties with mobility within the home?
*
No difficulties
Occasional difficulties
Frequent difficulties
Does the individual have access to a support network (family, friends, neighbors)?
*
Yes, regularly
Yes, occasionally
No support network
Are there any safety concerns in the current living environment?
*
No concerns
Some minor concerns
Significant safety concerns
How often does the individual participate in social or community activities?
Frequently
Occasionally
Rarely or never
Additional comments or observations
Submit Assessment
Should be Empty: