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Run: ADL Self-Care Assessment

Use this ADL Self-Care Assessment template to document observed independence in bathing, dressing, grooming, toileting, and feeding, with assistance levels a...

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Assessment Details

Assessment date and time recorded

Assessment setting documented

Primary observer identified

Reason for assessment documented

Prior ADL baseline available for comparison

Yes No N/A

Recent change in function noted

Note (optional)

Bathing

Initiates bathing task without cueing

Completes washing of body parts observed

Manages bathing supplies and water safely critical (required)

Transfers in and out of tub, shower, or bathing area safely critical (required)

Bathing assistance level documented

Note (optional)

Bathing safety concerns or non-conformance noted

Dressing and Grooming

Selects appropriate clothing for the task

Dons and doffs upper body clothing

Dons and doffs lower body clothing critical (required)

Completes grooming tasks observed

Uses adaptive equipment or compensatory techniques as needed

Note (optional)

Dressing and grooming assistance level documented

Note (optional)

Toileting and Feeding

Completes toileting sequence safely critical (required)

Manages clothing and hygiene after toileting

Transfers on and off toilet safely critical (required)

Feeds self using appropriate utensils and pacing

Swallowing, choking, or aspiration concern observed critical (required)

Yes No N/A

Toileting and feeding assistance level documented

Note (optional)

Summary and Follow-Up

Overall ADL independence level critical (required)

Note (optional)

Primary barriers to independence documented

Recommended follow-up or intervention documented

Progress since last assessment

Note (optional)

Get your results

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