Transportation: Can drive own car or use public transportation independently Can arrange own transportation using taxis, friends, etc. Uses private or public transportation with assistance Is unable travel at all Meal Preparation: Plans, prepares, and serves meals independently Prepares meals with occasional assistance Can heat and serve already prepared meals Needs to have meals prepared and served Housekeeping: Maintains house alone Performs some tasks but home is not at an acceptable level of cleanliness Needs help with all home maintenance tasks Laundry: Does all laundry independently Launders small items, such as hand wash items All laundry must be done by others Telephone Usage: Able to use telephone independently Able to dial frequently used telephone numbers unassisted. Able to answer the phone unassisted, but requires help to dial numbers Does not use the telephone Shopping: Does all shopping independently Needs to be assisted with shopping Is not able to shop Medications Management: Takes medication independently with correct doses at correct time Takes medication if it set up in advance in separate dosages Cannot take own medication Financial Management: Manages financial matters independently Manages day-to-day purchases, but needs help with banking, major purchases, etc. Unable to handle financial matters Toileting: Able to use the restroom independently Needs limited assistance Totally dependent on assistance Continence: No accidents Occasional accident (once/week or less) Incontinent Grooming: Independent in brushing hair, brushing teeth, etc. Needs some help in brushing hair, brushing teeth, etc. Totally dependent in brushing hair, brushing teeth, etc. Eating: Can feed self independently Needs some help (such as cutting things up) Totally dependent Transfer: Can move between surfaces independently (such as from chair to bed) Can move between surfaces with minor assistance Requires major assistance to move between surfaces Is unable to transfer alone Mobility: Can walk without help Uses an assistive device (cane, walker, etc.) Needs physical assistance to walk Uses a wheelchair Unable to move self at all Dressing: Can dress self Needs assistance Totally dependent Bathing: Can bathe/shower self independently Can bathe/shower with some assistance Dependent on others to bathe/shower Housing: Housing situation is currently stable Considering moving to an independent apartment or other independent setting Considering moving to a subsidized rental unit Considering placement in assisted living, residential care, or skilled nursing Social Connections: (Check all that apply) Interested in senior congregate meals Interested in home delivered meals Interested in senior activities Interested in volunteer opportunities I am a caregiver for an older adult Medicare/Medicaid Status Does this person receive Medicaid/MO Health Net? Yes No Not sure Does this person need assistance with Medicare premiums or copayments? Yes No Contact Information Name of individual completing the form: * Person the information is provided for: * Relationship to individual completing form: * Address: * City: * State: * - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: How would you prefer to be contacted? Phone Email Phone: Email: Comments/Other Concerns: Type this code: *