Independent Skills Assessment Scale Summary |
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PARTICIPANTS NAME |
INDEPENDENT |
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ASSISTANCE NEEDED |
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DATE |
AGE |
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VERBAL |
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GESTURAL |
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AGENCY |
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PHYSICAL ASSISTANCE |
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REFUSAL |
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PERSON OR TEAM SCORING |
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FUNCTIONALLY
INCAPABLE |
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Total = I+V+G+P+R+FI |
PARTICIPANT'S CURRENT RESIDENCE |
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(Subtract N/A items) |
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% INDEPENDENT |
SKILL AREA |
I |
V |
G |
P |
R |
FI |
TOTAL |
= (I / TOTAL) |
Meal Planning and Preparation |
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Shopping |
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Money Management and Budgeting |
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Personal Medications, First Aid, Health |
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Telephone and Other Utilities |
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Personal Appearance and Hygiene |
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Apartment/Home Maintenance, Upkeep |
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Personal Safety, Use of Emergency Resources |
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Civil Rights and Responsibilities |
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Social Recreational and Transportation |
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Coping Skills and Behavior |
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TOTALS |
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Current
level of Community Integration |
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Available Community
Support |
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% |
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% |
Consumer
Characteristics |
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Explain any NO answers |
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• Ambulates Independently |
Yes
/ NO |
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• Coordination is good |
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Yes
/ NO |
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• Well-being is maintained without
medications |
Yes
/ NO |
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• Vision is normal |
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Yes
/ NO |
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• Hearing is normal |
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Yes
/ NO |
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• Eats a regular diet |
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Yes
/ NO |
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Primary
Communication Mode |
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Quality |
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Current
Diagnosis |
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Current
Services Being Provided |
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