Six areas, the way a clinician scores them. Fill it in on an ordinary day, date it, and keep it — the comparison with the next one is what decisions get made on.
Name: ______________________________
Date: ____________________
Assessment completed by: _______________
Lives: alone / with others ____________
| Bathroom — tub or shower, floor, toilet height, anything to hold | |
| The route from bed to toilet at night, walked with the lights off | |
| Stairs — rails, step edges, anything stacked on them | |
| Fridge and stove — food in date, pans, scorch marks | |
| Medicine cabinet — duplicates, expired, how much is left | |
| Floors — loose rugs, cords, a worn track across the carpet | |
| Mail — opened, unopened, reminders |
The six the Katz index scores. Mark how it is TODAY, not how it was.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Bathing or showering | ||||
| Dressing | ||||
| Using the toilet | ||||
| Getting in and out of bed or a chair | ||||
| Continence | ||||
| Eating |
The eight on the Lawton scale. These usually slip first, often years earlier.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Using the telephone | ||||
| Shopping | ||||
| Preparing food | ||||
| Housekeeping | ||||
| Laundry | ||||
| Transportation / getting out | ||||
| Managing medication | ||||
| Managing money and mail |
Include aids already in use, and anything used as an aid that was not meant to be.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Walking indoors | ||||
| Walking outdoors | ||||
| Stairs | ||||
| Standing up from a chair | ||||
| Uses a cane, walker or rollator | ||||
| Steadies on furniture to cross a room |
Judgment matters more than memory. Note examples, not impressions.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Knows the day and where they are | ||||
| Repeats questions or stories | ||||
| Remembers recent conversations | ||||
| Decisions that make sense | ||||
| Has left the stove, faucet or door unattended | ||||
| Has gone out and become disoriented |
Compare what is prescribed against what is actually taken.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Knows what each medicine is for | ||||
| Fills the box without help | ||||
| Doses missed in the last week | ||||
| Doses doubled in the last week | ||||
| Duplicates or expired boxes in the house | ||||
| Pharmacy and doctor details recorded |
The area families can change fastest, and the one that buys the most time.
| Item | No help | Some help | Full help | What you saw |
|---|---|---|---|---|
| Something to hold in the tub or shower | ||||
| Non-slip surface where it is wet | ||||
| Toilet height workable | ||||
| Lit route from bed to toilet at night | ||||
| Rail on both sides of the stairs | ||||
| Loose rugs and trailing cords dealt with | ||||
| A way to call for help from the floor |
A fall in the past year is the strongest single predictor of the next one. Count the near misses too.
| When | Where and what happened | Injury / seen by a doctor |
|---|---|---|
Most people sit between two levels. The honest answer is usually the higher one.
| ☐ | Aging in place with aids | Independent in ADLs, maybe slipping on an IADL or two. Needs equipment and a safer house, not care. |
| ☐ | In-home care | Needs reliable help with specific things on specific days. Hours rather than a move. |
| ☐ | Assisted living | Daily hands-on help with bathing, dressing or medication, but not nursing. |
| ☐ | Memory or nursing care | Wandering, judgment that creates real danger, or medical needs that do not stop at night. |
The three things to change this week:
1.
2.
3.
Reassess on (six months): ____________________
This form is a structured way to record what you observe. It is not a medical assessment and does not diagnose anything. 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. © ElderlyDaily.com — free to print and use.
