Check the box if you have any difficulties with the following:

If so, what are some strategies to make the activity easier?

□  Bathing/Showering

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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□ Dressing

Strategies to make activity easier:

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□ Toileting (getting on/off toilet)

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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□ Functional mobility (getting in/out of bed, chair or, shower)

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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□ Grooming

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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□ Sexual activity

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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□ Sleep/rest

Strategies to make activity easier:______________________________________

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□ Managing medications (organizing, knowing when to take them)

Strategies to make activity easier:­­­­­­­­­­­­­______________________________________

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