SECTION IV ASSESSMENT – Please provide detailed information about how you are living your day-to-day life. Be specific about the challenges that are keeping you from meeting your long term care goals and/or needs. Preparing Meals Bathing/dressing Entering/exiting my home Other In my day-to-day life, I need assistance with the following that 1. Driving Please explain: impact my safety, independence and mobility: Check the appropriate box to indicate which obstacles require assistance from others. My bathroom My vehicle My kitchen Areas outside my home My doorways Other Barriers to my independence in my home, neighborhood and My living areas Please explain: 2. community include: My bedroom Check the appropriate box to indicate which obstacles require assistance from others. Describe any other relevant information or obstacles that 3. affect your safety, independence or mobility. Accessibility assessors may have different recommendations depending on your current health issues. Please share any 4. relevant information about any medical conditions, current or upcoming, that may impact your independence.
SECTION IV – ASSESSMENT Please provide detailed information about how you are living your day-to-day life. Be specific about the challenges that are keeping you from meeting your long term care goals and/or needs. 1. In my day-to-day life, I need assistance with the following that impact my safety, independence and mobility: Preparing Meals Entering/exiting my home Driving Bathing/dressing Other Please explain: Check the appropriate box to indicate which obstacles require assistance from others. 2. Barriers to my independence in my home, neighborhood and community include: My bathroom My kitchen My doorways My living areas My bedroom My vehicle Areas outside my home Other Please explain: Check the appropriate box to indicate which obstacles require assistance from others. 3. Describe any other relevant information or obstacles that affect your safety, independence or mobility. 4. Accessibility assessors may have different recommendations depending on your current health issues. Please share any relevant information about any medical conditions, current or upcoming, that may impact your independence.
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