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Needs Inventory Worksheet

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

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

____ 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_____________________

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

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

____ 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

____ Level of assistance required _____________________
____ How often? _____________________
____ Where is laundry done? _____________________

____ 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: