The purpose of the PersonalChoice Functional Assessment is twofold. It is
designed to provide a user-friendly method to determine an applicant’s personal
care assistance needs, which will be utilized to verify if in fact the applicant
meets a Nursing Facility level of care, as well as establish the participant’s
individual monthly budget. The Assessment is also designed to provide an
opportunity to engage the applicant in a dialogue, which will assist the applicant
in identifying goals that will improve his/her independence in areas of community
living (i.e. housing, transportation, benefits, employment/volunteering, etc.)
When completing the Assessment the applicant should be the source of the
majority of the information provided. If the applicant cannot provide some of the
information needed then alternative sources can be used, however the
applicant’s goals should be respected. The applicant has the option of involving
any person(s) of their choice in the assessment process. If, in fact, the applicant
has or requires a designated representative, that person should be present
during the assessment. Please utilize the notes section of the assessment to
record any observations or inconsistencies in the information provided by the
applicant or anyone else providing information. The majority of the assessment is
designed to be direct questions from the assessor to the applicant but several of
the questions are designed for the assessor to record his/her observations or
information gathered from other sources (i.e. Representative, care giver, family
etc.). For ease of use those questions are shaded.
There are more specific directions for the completion of the ADL/IADL Grid just
prior to that portion of the assessment.
A copy of this assessment should be forwarded to the Department of Human
Services, PersonalChoice program office upon completion.
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Gender Personal Demographics ____ Male ____ Female Last Name Marital Status Single _____ Married_____ First Name Middle Initial Partner_____ Widowed____ Divorced___ Separated____ Current Address Line 1 Other_______________________
Current Address Line 2
American Indian or Alaskan Native ___ City State Zip Code Asian/Pacific Islander _____ Black or African American ______ Email address White Hispanic _______ ( ) White Non-Hispanic _______ Telephone Number Other _______
Mailing Address (if different) Primary Language _____________ City Secondary Language ___________ State Zip Code Referral Source and Address Date of Birth Social Security # Referral Date
Medicare # / /
Assessment Date Medicaid # / /
_______________________________ Other Medical Insurance #
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Participant Benefits Information Name and Address and telephone #of
additional source of Information for
Does the Participant want assistance this Assessment (if not Participant)
in researching and applying for
available benefits? (i.e. Food Stamps, Utility Discounts, Tax Exemptions, etc.) ________ ________ Emergency Contact Information Yes No
Emergency Contact Name and Does the Participant want additional Telephone #(s) information on Legal Instruments? (i.e. Durable power of Attorney for Health ( ) Home Care, Living Will, DNR/DNI) ( ) Work
Yes _____ No_________ ( ) Cell
Basic Medical Information
Name, address and Phone number of Participant’s Primary Care Physician Name and Address of Representative
Telephone #(s) ( ) Home
Self Reported conditions/diagnoses ( ) Work
( ) Cell
Primary Diagnosis Relationship of Representative to
Substitute Decision Maker
None________ Representative Payee _______ In the past 30 days has the Participant Durable Power of Attorney for Health Care ____ experienced any troubling skin Power of Attorney ________ conditions (burns, bruises, rashes, Legal Guardian ________ open areas, breakdowns)
____ No Name, Address and Phone # of ____ Yes Substitute Decision Maker Being Treated? __________
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Is the participant experiencing any
difficulties in accessing medical care?
____ Yes ____ No ____ Hears only when the speaker makes special efforts (e.g. louder If yes, in what areas? (i.e. specialists, voice) dental, vision, availability of ____ Highly impaired (absence of transportation etc.) _______________ Ability to speak and verbally express useful hearing) himself or herself. ____ Deaf
____ No observable problem ____ Minimal difficulty Medications ____Moderate difficulty ____ Severe difficulty Does the Participant take any
Prescription Medications on a regular basis? ____ Unable to express basic needs
Yes ______ No_______
Devices Participant uses to
communicate or understand others
____ Augmentive Communication Device Vision, Hearing and Speech ____ Eyeglasses/corrective lenses Indicate the Participant’s current ____ Hearing aide, present and not used vision quality (with glasses, if they are regularly regularly used) ____ Hearing Aide, present and used ____ Adequate (sees fine detail) ____ Interpreter (language) ____ Interpreter (sign) ____ Impaired (sees large print) ____ Lifeline ____ Moderately Impaired (limited vision) ____ Magnifying glass ____ Highly Impaired (sees some ____ Other receptive comm. techniques used objects) (e.g. lip reading) ____ Severely Impaired (sees only ____ Other visual aids light and shadows) ____ Picture Book/Symbol book ____ Other visual deficits (i.e. visual field cut, reduced depth perception, hemianopsia, ____ Relay RI etc.) ____ TTY (teletypewriter) ____ None of the above Participant’s Ability to hear (with a hearing appliance if used). ____ Adequate, hears doorbell and phone ____ Minimal difficulty when not in quiet setting ____ Has moderate difficulty hearing
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What is the participant’s current level Is the Participant currently receiving of cognitive functioning? any treatments and/or therapies? _____Yes(describe below) _____ No ____ Alert/Oriented ____ Requires prompting under stressful or unfamiliar conditions ____ Requires assistance/direction or low stimulus environment ____ Requires considerable assistance in routine situations Psychological, Social and ____ Totally dependentBehavioral Screen
Does the participant express any
concerns regarding his/her emotional
Describe the participant’s wandering health?
tendency. ____ Yes ____ Does not wander ____ No ____ Wanders mostly inside ____ Wanders outside, but does not get lost If yes, does the participant feel that ____ Wanders outside, leaves and gets lost these issues have negatively affected his/her life and/or relationships with ____ Cannot wander secondary to physical issues others?
____ Yes ____ No Check all that apply to participant’s
____ Pleasant and Cooperative Is the participant open to further exploration/treatment for these issues? ____ Usually Socially Appropriate ____ Sometimes disruptive or socially ____ Yes inappropriate ____ No ____ Frequently disruptive or socially inappropriate Does the participant feel it would be beneficial to be connected with a peer
Check all that apply to participant’s to discuss disability related issues or
behaviors toward self and others. problems?
____ Verbally abusive ____ Yes ____ Physically threatening ____ No ____ Physically abusive ____ A danger to self and others RI DHS PersonalChoice Functional Assessment Rev. 1/5/06 Page 5 of 13
How easily can above behaviors be
____ Easily ____ With difficulty ____ With other family member Is this his/her preferred living ____ Cannot alter ____ With friend arrangement? ____ Unable to determine ____ Other ____ Yes Housing ____ No Where is the Participant currently
Does the participant want additional residing?
information and/or assistance in
____ Own home/condo exploring his/her housing options? ____ Rents home/condo ____ Yes ____ Rents apartment ____ No ____ Subsidized/public housing ____ Room and board/Roomer Home Safety and Accessibility ____ Family home ____ Mobile Home Does the participant have a way to exit the home independently in the event ____ Group Home of an emergency? ____ Assisted Living ____ Yes ____ LTC institution/nursing home ____ No ____ Homeless ____ Other Does the participant have a way to summon help in the event of an
____ Yes Is this his/her preferred housing arrangement? ____ No
____ Yes Transportation ____ No Indicate how the participant travels to Select the Participant’s current living and from activities. arrangement. ____ Drives self ____ Lives alone ____Family/friend ____ With spouse/partner ____ Drives self but requires assistance (i.e. load wheelchair, etc.) ____ With spouse and child/children ____ Public Transportation (RIPTA) ____ With child/children ____ Paratransit/RIDE ____ With adult child ____ Other/Does not leave the home ____With Parent or guardian
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Is the participant presently Is the participant interested in volunteering? learning more about available transportation, including adapted ____ Yes vehicles (if needed), to increase their ____ No community access? ____ Yes Does the participant wish to locate a ____ No volunteer activity and/or obtain
assistance in finding a volunteer
activity? Does the participant have a
handicapped-parking placard? ____ Yes ____ Yes ____ No ____ No
Does the participant feel that they have sufficient activities available to Other Community Living Needs them, both in the home and in the community? Is the Participant currently enrolled in any educational program? ____ Yes ____ No ____ Yes ____ No Does the participant want assistance in Does the participant wish to pursue identifying and locating activities any educational goals at this time (e.g. available to them, either in the home GED, Degree Program, Adult education, or in the community? enrichment program)? ____ Yes ____ Yes ____ No ____ No Is the participant registered to vote? ___ Yes
Is the participant presently employed ___ No in any capacity? If No do they wish to register to vote? ____ Yes ____ No ____ Yes ___ No
Is the participant interested in acquiring paid employment and/or referral for Vocational Rehabilitation services? ____ Yes ____ No
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_______________________________ Does the Participant currently receive any services in the home? (i.e HHA, homemaker, Meals on Wheels, skilled Goal #3 ________________________ nursing, etc).
______Yes (please list) _______ No _______________________________ Notes
Please utilize this section to document any issues or observations that occurred during the assessment process, or to document anything not
covered anywhere in the assessment Does the Participant currently receive that would effect this individuals any services in the community? (i.e. participation in the program. Meal Site, Senior Center, support group, Mental Health services, etc.) ____ Yes (please list) ______ No Does the participant request assistance in identifying and obtaining additional home or community services?
____ Yes ____No
Briefly summarize any goals the participant identified during the assessment process. Goal#1 ________________________
Goal #2 _______________________
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Assistance Required for ADLs and IADLS Assessment Grid
Directions for Completion of the ADL/IADL Assessment Grid
The completed assessment grid will be utilized by the Department of Human Services to
determine the Participant’s total need for assistance in the safe and timely completion of their
ADLs and IADLs and subsequently to determine the dollar amount of their monthly budget.
Determination of the participant’s need for assistance should be based on the current amount
of assistance needed in all of the indicated areas taking into account any adapted equipment
currently being used (i.e. tub bench, dressing stick etc.) and the frequency that it is required.
Care provided by a spouse should not be included in this assessment. Both level of assistance
and frequency should be based on the participant’s report and preferences. The assessor
should not assign a level of assistance or frequency of assistance that is contrary to what the
participant reports. If there is a question in the assessor’s mind as to the truth of the
participant’s report, it should be indicated in the notes section of the assessment. Also the
frequency of assistance that is recorded should be based on the participant’s preference, not
the current frequency; (i.e. participant wishes to shower daily but is not doing so currently due
to lack of available assistance); or the assessor’s opinion (i.e. participant wishes to shower weekly, but assessor feels they should shower more often).
For each section of the assessment grid the assessor should indicate by circling the appropriate
number score corresponding to the amount of assistance required for each section (utilizing
the key for definitions). The assessor should also indicate if any special equipment is used in
the areas of Bathing, Mobility, Toileting and Transferring by checking the appropriate items.
The assessor should indicate the frequency the assistance is needed for each item, (i.e. daily,
twice a day, weekly, every two days, etc.). Again this should be based on the participant’s
report and preferences.
Note: In the areas of Bathing and Toileting please indicate assistance required for each sub-
type (i.e. Sponge Bath, Tub Bath, Shower; Urinary, Bowel and Menses) and frequency it occurs
(both times per day and days per week).
Type # Days/wk. Bathing: The ability to shower, bath or take sponge Sp. B T.B. Sho. Sponge Bath __baths for the purpose of 2___ 1 1 1 maintaining adequate hygiene. 1 2 2 This also includes the ability to Tub Bath get in and out of the __5___ 3 3 3 tub/shower, turn faucets on & off, regulate water 4 4 temperature, wash and fully Shower 4 dry. _____ 5 5 5 ___Uses Shower Chair, Tub Bench, Grab Bars or 6 6 6 Mechanical Lift
7 7 7
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1 Independent- Participant is independent in completing the task safely 2 Supervision- Participant requires supervision, cuing, reminding and/or setup assistance to
perform task. This level entails brief supervision only.
3 Minimum Assistance- Participant is actively involved in activity, requires some hands-on
assistance for completion, thoroughness or safety. Needs verbal or physical assistance with
25% of activity
4 Moderate Assistance- Participant requires extensive hands-on assistance but is able to assist in
the process. Needs verbal or physical assistance with 50% of the activity 5 Maximum Assistance- Participant requires verbal or physical assistance in the performance of
75% of the task.
6 Dependent- Participant requires 100% (total) assistance with the activity 7 Participant requires assistance but is not requesting paid assistance
Type #days Bathing: The ability to shower, bath or take sponge Sp. B T. B Sho. per baths for the purpose of maintaining adequate hygiene. Sponge 1 1 1 week This also includes the ability to get in and out of the Bath 2 2 2 ____ 3 3 3 tub/shower, turn faucets on & off, regulate water Tub 4 4 4 temperature, wash and fully dry. bath 5 5 5 ____ 6 6 6 ___Uses Shower Chair, Tub Bench, Grab Bars or Shower 7 7 7____ Mechanical Lift
Per #days Dressing: The ability to dress and undress as necessary and dayper 1 choose and retrieve appropriate clothing. Includes the ability to 2 weekput on prostheses, braces, antiembolism garments (e.g. “TED” 3 stockings) or assistive devices, and includes fine motor 4 5 coordination for buttons and zippers. Includes choice of clothing 6 appropriate for the weather. Difficulties with a zipper or buttons 7at the back of a dress or blouse do not constitute a functional deficit.
Per #days Eating: The ability to eat and drink using routine or 1 dayper adapted utensils. This also includes the ability to cut, 2 week3 chew and swallow food. Note: If the person is fed via tube 4 feedings or intravenous, circle 1 if they can do it 5 6 themselves, or 2,3,4,5,6 or 7 if they require assistance 7
Per #days Mobility: The ability to move between locations in the 1 dayper person’s living environment inside and outside the home 2 weekwith or without an assistive device. 3 4 ___ Uses Walker, Cane or Crutches 5 ___ Uses Wheelchair (manual or power) or Scooter 6 7___ Has Prosthesis ___ Wall or Furniture Walking
Per #days Toileting: The ability to use the toilet, commode, bedpan Ur. Bow. Men. day per or urinal. This includes transferring on/off the toilet, week 1 1 1 cleansing of self, changing of pads, managing an ostomy Urinary 2 2 2 _____ ______ or catheter, and adjusting clothes. 3 3 3 ___ Uses Commode or other Adapted Equipment Bowel 4 4 4 ___ Has Ostomy _____ ______ 5 5 5 ___ Uses Urinary Catheter (External or Indwelling) Menses 6 6 6 ___ Intermittant Catheterization Program _____ _____ 7 7 7 ___ Receives Regular Bowel Program
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