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Needs Inventory Form

Suggestions for Using the Sample Needs Inventory

This sheet is to help you jump start focusing your thoughts generally on what you need.

Use the line to the left of the heading in Bold Type to indicate that you need help with this task. Use the lines on the left of the subcategories of this heading to tick off when you have added this item to the work schedule. The spaces to the right are for the details (what type of bath? Shower frequency? Mon, Wed, Fri., etc.) Use the last sheet for any additional details.

Personal Assistant Services

Needs Inventory

Personal Care Needs

Bathing:
         Type of bath (shower, bed bath, setup)
         Frequency (daily, 3 times a week)
         Time of Day
         How long does it take?

Dressing:
         Level of assistance (partial, total)
         Special considerations (need support stockings, upper- body help only)
         How long does it take?

Oral Hygiene:
         Frequency
         Type of assistance required

Bowel Care:
         Type of bowel program, if any (in bed, on commode, etc)
         Frequency of bowel care
         Time of day
         How long does it take?

Bladder Care:
         Type of bladder program, if any (ICP, condom cath, suprapubic, etc.
         Frequency of bladder care
         Time of day

Transfers:
         Type of transfer (dependent, sliding board, etc.)
         Amount of assistance required
         When needed

Eating:
         Other than meal prep ~ any special help (adaptive equipment, set-up, total assistance)
         Special diet

Medication:
         Type of medications (make a separate list if necessary)
         Frequency
         Who administers?

Exercise program:
         Type of exercise program (ROM, strengthening, etc.)
         Frequency
         How long does it take?

Homemaking Needs

Laundry:
         Level of assistance required
         How often?
         Where is laundry done?

Housecleaning:
         Frequency
         Number of rooms
         Specific Chores

Meal Preparation:
         Time of meals
         Who will plan?

Grocery Shopping:
         Frequency
         Where is shopping done?
         Who is responsible?

Additional "Needs Assessment" Comments/Notes:

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