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