1.1: Meeting Personal Care needs |
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Thinking about your personal needs: | Score |
A) I am able to manage my personal care needs. | 0 |
B) I occasionally need help with my personal care, perhaps once or twice a week and with specific tasks (bathing, shaving, taking medication). | 1 |
C) I need help with my personal care, perhaps once a day. | 2 |
D) I often need help with my personal care, perhaps twice a day. | 8 |
E) I need constant help with my personal care, more than twice a day. | 12 |
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1.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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2.1: Night Care |
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Thinking about your nightcare needs: | Score |
A) I have no nightcare needs. | 0 |
B) I occasionally need help at night, perhaps once or twice a week and with specific tasks | 1 |
C) I need help every night, perhaps once a night. | 2 |
D) I often need help at night, perhaps twice a night. | 8 |
E) I need constant help at night, more than twice a night. | 12 |
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2.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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3.1: Careworker/s |
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Thinking about your need for additional careworker/s: | Score |
A) I have no need for additional careworker/s in addition to family/friends or other persons | 0 |
B) I occasionally need additional help from careworker/s, perhaps once or twice a week and with specific tasks (bathing, shaving, taking medication). | 1 |
C) I need additional help from careworker/s with my personal care, perhaps once a day. | 2 |
D) I often need additional help from careworker/s, perhaps twice a day. | 8 |
E) I need additional constant help from careworker/s, more than twice a day. | 12 |
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| Final Score for Question |
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4.1: Eating and Drinking (Nutritional) needs |
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Thinking about your eating and drinking needs: | Score |
A) I don't need help at mealtimes. I manage eating, drinking and preparing my own meals. | 0 |
B) I need help with the preparation of some meals and drinks, ensuring foods are within their sell-by date and cooking them safely. | 1 |
C) I need all my meals and drinks prepared for me. | 2 |
D) I need all my meals and drinks prepared and served to me. I need some help to guide or assist with eating and drinking. | 8 |
E) I need all my meals and drinks prepared and served to me. I need a lot of help with eating and drinking. | 12 |
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4.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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5.1: Practical aspects of Daily Living |
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Thinking about practical aspects of daily living: | Score |
A) I manage these day-to-day tasks myself. | 0 |
B) I manage most day-to-day tasks myself but need help with one or more specific tasks (such as particular housework tasks, laundry or shopping). I need this help once or twice a week. | 1 |
C) I manage some day-to-day tasks myself but need help with several specific tasks (such as particular housework tasks, laundry or shopping). I need this help three or four times a week. | 2 |
D) I need help with most day-to-day tasks (housework, cleaning, shopping, managing finances, correspondence etc). I need this help daily. | 4 |
E) I need a lot of help with all day-to-day tasks (such as housework, cleaning, shopping, managing finances, correspondence etc). I need constant assistance. | 6 |
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5.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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6.1: Risk of Harm in the Home |
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Thinking about your own safety and risks: | Score |
A) I don't need help to stay safe. I've rarely done things that could endanger myself or others and people are not generally concerned for my safety. | 0 |
B) I need a little help to stay safe, at specific times and with certain activities. I've occasionally done things that could endanger myself or others and people are sometimes concerned for my safety. | 0 |
C) I need frequent help to stay safe with various activities - I need this help at least three times a week. I've occasionally done things that could endanger myself or others and people are sometimes concerned for my safety. | 0 |
D) I need help to stay safe the majority of the time and with most activities - I need this help daily. I've occasionally done things that could endanger myself or others and people are concerned for my safety. | 8 |
E) I need constant supervision to stay safe with all activities. I often do things that endanger myself or others and people are very concerned for my safety. | 12 |
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| Final Score for Question |
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7.1: Safety and Risk Getting Around |
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Thinking about your orientation and mobility needs: | Score |
A) I don't need help to make journeys inside and / or outside of the home. | 0 |
B) I am capable of making most journeys without help inside and outside of the home. I sometimes need assistance with long, difficult or unfamiliar journeys. | 0 |
C) I need some help to make journeys inside and / or outside of the home. There are some journeys I can manage, mostly inside, but these are very few. | 0 |
D) I need frequent help to make most journeys outside of the home.
I can get around inside the home. | 2 |
E) I need help to get around inside of the home most of the time. | 6 |
F) I need help with all journeys. There are no journeys I am able to make on my own inside or outside. | 10 |
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7.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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8.1: Choice and control |
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Thinking about how much choice and control you have: | Score |
A) I don't need help to make choices or decisions. I make day-to-day as well as bigger decisions about my life. I may need a bit of advice occasionally but I have full capacity and understanding. | 0 |
B) I am able to make most choices and decisions. I make day-to-day decisions but I need support when making bigger decisions about my life (Or information is sometimes in a format that is inaccessible to me and I need help with this). | 0 |
C) Other people make the majority of the decisions about my life. I need support to make more decisions. | 6 |
D) Other people make all the decisions about my life. I need a lot of support to take greater control of the decisions made on my behalf. | 11 |
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8.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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9.1: Relationships, Family and Friends |
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Thinking about your relationships, friends and family: | Score |
A) I'm content as things are. I don't need support to maintain the friendships I have or see my family. | 0 |
B) I occasionally need support to maintain the friendships I have and see my family. I need this support once or twice a week. | 1 |
C) I need frequent support to make new friends, maintain the friendships I have and see my family. I need this support at least three times a week. | 2 |
D) I need support the majority of the time to make new friends, maintain the friendships I have and see my family. I have one or two friendships but not enough for me. I need this support at least four times a week. | 4 |
E) I need support all of the time, every day to make new friends and see my family. I don't have any friendships outside my family and carers and this affects the quality of my life. | 6 |
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9.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |
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| Final Score for Question |
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10.1: Work, Leisure, Learning and Enjoying Life |
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Thinking about your work, leisure and learning needs: | Score |
A) I am content as things are. I have the opportunities I need to work and/or learn new things. I take part in the community activities that I wish. | 0 |
B) I occasionally need some support to make the most of opportunities to work and/or learn new things as well as take part in the community activities that I wish. I need this support once or twice a week. | 1 |
C) I need frequent support to develop opportunities to work and/or learn new things as well as take part in the community activities that I wish. I need this support at least three times a week. | 2 |
D) I need support the majority of the time to develop opportunities to work and/or learn new things as well as take part in the community activities that I wish. I need this support at least four times a week. | 4 |
E) I need a lot of support all of the time, every day to develop opportunities to work and/or learn new things as well as take part in the community activities that I wish. | 7 |
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10.2: Thinking about Informal Care: | Factor |
How much support are your family/friends or other persons willing and able to provide to support you in this area? | 0 |