Home Care Assessment Form

A printable form covering the six areas a clinician scores. Fill it in on an ordinary day, write down what you actually saw, and date it. No sign-up, no email address.

Open the printable form Answer seven questions instead

What the form covers

The form follows the same structure a visiting assessor uses, so what you record lines up with what a nurse, social worker or care manager will ask about. Two of the six areas come from scales that have been in clinical use for decades and that you will see named in any care plan.

Activities of daily living (ADLs)

Bathing, dressing, toileting, transferring, continence, eating — the six the Katz index scores. Trouble here is what moves someone from needing help to needing care.

Instrumental activities (IADLs)

Phone, shopping, cooking, housekeeping, laundry, transport, medication, money — the eight on the Lawton scale. These slip first, often years earlier.

Mobility

Indoors, outdoors, stairs, standing from a chair, aids in use — including furniture being used as one.

Memory and judgment

Orientation, repeated questions, decisions that do not make sense, the stove left on, going out and becoming disoriented.

Medication

What is prescribed against what is actually taken, who fills the box, doses missed or doubled.

The home itself

Bathroom, stairs, lighting, the night route to the toilet, and whether help is within reach.

How to use it

1Print it before the visit. Trying to fill this in on a phone while talking to someone does not work.
2Walk the house first and complete the observation page before you ask a single question. The fridge, the bathroom floor and the pill box are more honest than any answer.
3Mark each item no help, some help or full help — then write the thing that made you choose it. "Some help" means nothing in six months. "Needed a hand out of the tub twice this week" means a great deal.
4Finish with the level of care and the three things to change this week. Three changes that get used beat ten that sit in a box.
5Date it and keep it. The comparison with the next one is the part that drives decisions.

This is a record, not a diagnosis. It is a structured way to write down what you observe so a doctor, social worker or agency has something concrete to work from. Sudden confusion, a fall with no clear cause, or a change over days rather than months is a reason to speak to a doctor promptly rather than to carry on filling in a form.

If you want the reasoning behind each question

The form is deliberately terse. Our step-by-step guide to doing a home care assessment explains what each area is really testing, how to ask the questions without starting a fight, and how to read the result — including the four levels of care and which one the answers point to.

Questions families ask

Is this home care assessment form free?

Yes. Print it, photocopy it, use it with a client, hand it to a sibling. There is no sign-up and no email address needed. We earn through affiliate links on our product reviews, not by gating the things families actually need.

What should a home care assessment form include?

Six areas: activities of daily living (bathing, dressing, toileting, transferring, continence, eating), instrumental activities (phone, shopping, cooking, housekeeping, laundry, transport, medication, money), mobility, memory and judgment, medication management, and the safety of the home itself. A usable form also leaves room to record what you actually saw, not just a score, and a date so the next assessment can be compared against it.

Can I use this form for a non-medical home care agency?

It covers the same ground a non-medical home care intake form covers, and plenty of small agencies and independent carers use a form like this. It is not a clinical assessment and should not be presented as one, and it will not satisfy a regulator who requires a specific state or provincial document.

What is the difference between ADLs and IADLs on the form?

Activities of daily living are the basic physical tasks of looking after yourself. Instrumental activities are the tasks of running a household. IADLs usually slip first, often years before ADLs do, which is why the form scores them separately rather than lumping everything into one list.

How do I score it?

Mark each item as no help, some help, or full help, and write down the thing that made you choose. The written note is the part that matters six months later, because “some help” means nothing on its own and “needed a hand getting out of the tub twice this week” means a great deal.

How often should I fill it in?

Every six months while things are stable, and straight after any hospital stay, fall or noticeable change. One form is a snapshot. Two forms six months apart show the direction and the speed, and that is the information a doctor will ask you for.

How to do a home care assessment — the full method.
Care needs assessment quiz — seven questions, no email.
Senior home safety checklist — the room-by-room walk-through.
Fall risk assessment — if falls are the worry.