Living Well at Home Assessment

Living Well at Home Assessment

The purpose for this worksheet is to help evaluate a senior’s ability to live safely and productively at home. Going through this worksheet will not only help identify ADLs (activities of daily living) they need help with, but also help them arrive to a decision they need help, which in the end is the toughest decision to make – accepting help in the home.

If you’d like this information can be evaluated by a registered nurse as part of a free in-home assessment for home care.  This worksheet can be a helpful aid prior to a discussion with Akin Care.

Please rate the level of Assistance for each of the independent activities of daily living (IADLS) described below:

  •   0 – Independent. Bills consistently paid on time without assistance.
  •   1 – Minimum Assistance. Occasional overdraft/overdue bill notices.
  •   2 – Moderate Assistance. Many unpaid bills/overdrafts, messages from creditors.
  •   3 – Total Assistance. Does not manage own finances.


  •   0 – Independent. Drives own vehicle, no accidents or tickets.
  •   1 – Minimum Assistance. Has had minor accident, passengers uncomfortable with their driving.
  •   2 – Moderate Assistance. More than one accident, gets confused on familiar roads, flustered with traffic.
  •   3 – Total Assistance. No longer drives.


  •   0 – Independent. Shops independently, prepares list, able to load and unload car.
  •   1 – Minimum Assistance. At times, runs out of essential household items, needs help to prepare lists and load/unload car.
  •   2 – Moderate Assistance. Consistently missing or has excessive amounts of essential household items, needs assistance preparing lists/while shopping/ loading and unloading car.
  •   3 – Total Assistance. No longer shops.


  •   0 – Independent. Makes own nutritious meals without help.
  •   1 – Minimum Assistance. Occasionally skips meals/chooses food with little nutritional value.
  •   2 – Moderate Assistance. Rarely prepares nutritious meals/consistently makes poor food choices/burned pan on stove.
  •   3 – Total Assistance. No longer prepares meals.


  •   0 – Independent. Answers phone consistently, returns voicemail messages consistently.
  •   1 – Minimum Assistance. Occasionally misses a phone call or forgets to return voicemail message.
  •   2 – Moderate Assistance. Rarely answers the phone or returns voicemail messages.
  •   3 – Total Assistance. Does not use the phone.


  •   0 – Independent. Takes medications as prescribed, refills meds, rarely misses a dose.
  •   1 – Minimum Assistance. Fills own pillboxes/forgets to take medication 2-3 times/week, occasionally runs out before refilling.
  •   2 – Moderate Assistance. Someone else fills pillboxes /forgets to take medication at least once/day.
  •   3 – Total Assistance. Someone else fills pillboxes and refills prescriptions/needs constant reminders to take medication throughout the day.


  •   0 – Independent. Home is in good repair, no clutter or safety issues.
  •   1 – Minimum Assistance. Home needs minor attention- dusting/vacuuming, has burned out light bulbs/dirty dishes, some clutter.
  •   2 – Moderate Assistance. Home needs significant attention- rooms including floors are cluttered, stairs/handrails need repair, appliances/HVAC in disrepair/yard overgrown.
  •   3 – Total Assistance. Home poses serious hazards- unsafe to live in.


Please rate the level of Assistance for each of the activities of daily living (ADLs) described below:

Please comment on behavior and State of Mind


Your Contact Information:


Senior’s Contact Information:

If you are completing this assessment for a senior, please provide their contact information.



Total Score:

Evaluating Your Score:

0-7 Support services may not be needed at this time

8-14 Consider support services for safety and to maintain independence

15-20 Support services strongly recommended for safety and to maintain independence

>20 Support services highly recommended as soon as possible

  I would like an Akin Care Senior Services RN to evaluate my worksheet and contact me with an initial assessment and recommendations

* Required