| 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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