Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 6
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15AG-095 (11-14) – Page 6
CLIENT’S NAME
DAARS ID NO.
C. Assessment of Daily Living Activities
For each activity, select the level of assistance needed, select the source of help, and select the qualifier, as needed.
Levels of Assistance
Qualifiers
1. Independent – Completes the task independently.
C – Cognitive
2. Minimum Assistance – Occasional assistance or supervision may be necessary.
I – Isolation
3. Moderate Assistance – Assistance or supervision is usually necessary.
S – Safety
4. Maximum Assistance – Totally dependent on others.
Source of Help
a. None
d. Friend
g. Private paid help
j. Sibling
m. Volunteer
b AAA provided
e. Other relative
h. Publicly funded help
k. Son
c. Daughter
f. Parent
i. Residential health care
l. Spouse/significant other
Activities of Daily Living
1. Ind
2. Min
3. Mod
4. Max
Source of Help
Qualifiers
Comments
Bathing
Dressing
Eating
Walking
Transferring
Toileting
Instrumental Activities of Daily Living
1. Ind
2. Min
3. Mod
4. Max
Source of Help
Qualifiers
Comments
Shopping for personal items
Doing heavy housework
Doing light housework
Using the telephone
Managing money
Transportation ability
Preparing meals
Medication management
COMMENTS
D. Assistive Devices
None.
For the following devices, select Has or Needs the device. If client does not have or need any device, select None.
Restore List
Has
Needs
Has
Needs
Has
Needs
Cane ...............................
Hoyer lift..........................
Mediset ................................
Quad cane ......................
Shower bench .................
Glucometer ..........................
Crutches .........................
Shower chair ...................
Test strips ............................
Walker.............................
Raised toilet seat ............
Dentures ..............................
Electric wheelchair ..........
Commode chair ..............
Hearing aids ........................
Manual wheelchair ..........
Hand-held shower ...........
Eye glasses .........................
Electric scooter ...............
Geri-chair ........................
Service dog .........................
Hospital bed ....................
Grab bars ........................
Emergency notification ........
Egg crate mattress ..........
Oxygen ...........................
Communication board .........
Hand rails........................
Oxygen mask ..................
Companion animals.............
Side rails half ..................
Nasal prongs/cannula .....
Assistive phone device ........
Side rails full ...................
Concentrator ...................
Other assistive device
(specify in comments) .........
Trapeze...........................
Portable oxygen ..............
Transfer board ................
Ventilator.........................
None ....................................
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