FIRST NAME     LAST NAME  

BIRTHDATE  
/ /
  GENDER  

Ability To Use Telephone
  1.     Uses telephone independently
  2.     Dials a few well known numbers
  3.     Answers telephone but does not dial
  4.     Unable to use the telephone
Shopping
  1.     Shops independently
  2.     Shops independently for small purchases
  3.     Needs to be accompanied when shopping
  4.     Unable to shop
Food Preparation
  1.     Independently plans, prepares and serves adequate meals
  2.     Prepares meals if supplied with ingredients
  3.     Heats and serves meals but diet is inadequate
  4.     Needs to have meals prepared and served
Housekeeping
  1.     Maintains home independently
  2.     Able to do light daily tasks (Bedmaking, dishes)
  3.     Does light tasks but level of clenaliness is inadequate
  4.     Unable to maintain home
Laundry
  1.     Independently does laundry
  2.     Launders small items
  3.     Unable to do laundry independently
Mode Of Transportation
  1.     Travels independently
  2.     Arranges own transportation (Taxi)
  3.     Uses public transportation with assistance<
  4.     Accompanied when traveling
  5.     Unable to travel
Responsibility Foe Own Medicine
  1.     Independently takes medications correctly
  2.     Takes medications independently if set up for them
  3.     Unable to take medications independently
Handling Finances
  1.     Handels finances independently
  2.     Manages day to day purchases but needs help
  3.     Answers telephone but does not dial