Lifestyle Evaluation

Medications

1. Understands own medication regimen and is able to take the medications correctly on own
2. Able to correctly take medications that family member has set up according to the physician's order
3. Needs reminders to take medication on time or needs assistance removing medication from container
4. Finds medication regimen and side effects confusing, needs assistance to administer
5. Dependent on others for the administration of medication (licensed nurse only) and needs physical assistance such as crushing or mixing medication with food

Bathing

1. Able to take care of hygiene including daily grooming and bathing, showering, dental hygiene
2. Needs set up of supplies for daily grooming and bathing
3. Needs reminder for showering or requires set up of supplies and setting of water temperature
4. Needs some physical assistance with bathing/showering, including washing and washing hair
5. Dependent on others for bathing/showering

Dressing

1. Able to fully dress and undress self on a daily basis
2. Needs family assistance with ensuring clothing is rotated through laundry
3. Needs clothes laid out daily and or reminders to change or needs assistance with shoes and socks, or buttons and zippers routinely
4. Needs assistance with dressing and undressing daily
5. Dependent on others for dressing and undressing

Nutritional Needs

1. Able to prepare balanced meals and eats independently
2. Prefers not to prepare all meals but eats independently
3. Dependent on others for preparation of all meals each day
4. Needs reminders to attend meals or assistance with choosing or cutting foods
5. Dependent on others for eating

Mobility

1. Able to move about independently and safely, able to evacuate in case of an emergency
2. Able to move about independently with use of assistive device such as a cane or wheelchair, able to evacuate
3. Needs verbal reminders for evacuation in case of emergency
4. Needs physical assistance with transferring but is active in the transferring process (able to bear weight and/or raise self from lying or sitting position to standing)
5. Dependent on others for mobility and safe evacuation, whether ambulatory or wheel chair mobile

Housekeeping

1. Able to do own light housekeeping
2. Able to do own personal laundry but needs help with changing linens, weekly dusting and vacuuming
3. Prefers that housekeeping services occur more than once per week
4. Needs daily trash removal or bed making
5. Needs trash removal more than once per day due to special needs such as incontinence

Additional Needs

1. No special needs
2. Needs to be checked on periodically throughout day
3. Needs calming or cueing on a routine basis due to memory or behavioral needs
4. Needs a secured area due to potential for, or actual wandering behavior related to memory problems, or needs availability of planned activities suited for individuals with mild or moderate memory problems
5. Dependent on others for safety, needs full physical, psychological, emotional support from staff due to more advanced memory problems