Screening- Does Client?
1. Use Telephone?	Yes No
2. Get out of bed unassisted?	Yes No
3. Walk Unassisted?	Yes No
4. Operate a motor vehicle?	Yes No
5. Shop for essentials?	Yes No
6. Handle money/ Pay bills?	Yes No
7. Prepare meals?	Yes No
8. Eat unassisted?	Yes No
9. Do routine housework?	Yes No
10. Do laundry?	Yes No
11. Dress and undress self?	Yes No
12. Shower/ Bathe/ Groom self?	Yes No
13. Get to toilet in time?	Yes No
14. See physician frequency?	Yes No
15. Follow medical directions?	Yes No
16. Have prescribed medications?	Yes No
17. Have diabetes?	Yes No
18. Receive home health?	Yes No
19. Have physician?	Yes No
20. Have physician ordered therapies?	Yes No
21. Have adequate informal supports?	Yes No
22. Seem confused?	Yes No
23. Have ability to share in cost of care?	Yes No
24. Other