Name of individual Date of completion C B A Cognition No evidence of impairment, confusion or Cognitive impairment (which may include Cognitive impairment that could for example disorientation. some memory issues) that requires some include frequent short-term memory issues supervision, prompting and/or assistance and maybe disorientation to time and place. OR with basic care needs and daily living The individual has awareness of only a Cognitive impairment which requires activities. Some awareness of needs and limited range of needs and basic risks. some supervision, prompting or basic risks is evident. Although they may be able to make some assistance with more complex activities choices appropriate to need on a limited The individual is usually able to make of daily living, such as finance and range of issues, they are unable to do so on choices appropriate to needs with medication, but awareness of basic risks most issues, even with supervision, assistance. However, the individual has that affect their safety is evident. prompting or assistance. limited ability even with supervision, OR prompting or assistance to make decisions The individual finds it difficult, even with about some aspects of their lives, which supervision, prompting or assistance, to Occasional difficulty with memory and consequently puts them at some risk of make decisions about key aspects of their decisions/choices requiring support, harm, neglect or health deterioration. lives, which consequently puts them at high prompting or assistance. However, the risk of harm, neglect or health deterioration. individual has insight into their impairment.
Name of individual Date of completion C B A Cognition No evidence of impairment, confusion or disorientation. OR Cognitive impairment which requires some supervision, prompting or assistance with more complex activities of daily living, such as finance and medication, but awareness of basic risks that affect their safety is evident. OR Occasional difficulty with memory and decisions/choices requiring support, prompting or assistance. However, the individual has insight into their impairment. Cognitive impairment (which may include some memory issues) that requires some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident. The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration. Cognitive impairment that could for example include frequent short-term memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues, they are unable to do so on most issues, even with supervision, prompting or assistance. The individual finds it difficult, even with supervision, prompting or assistance, to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration.