1 Financial
2 Social/Emotional
3 Health
4 Physical
5 Personal
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INTERVIEWER: Read each and circle all that apply
Description
Source of information
Financial = (cash, paying for bills, fees, food, medicines)
Social/Emotional = (social support, counseling, time with friends, "parenting" time)
Health = (providing health care - administering medicines, changing bandages, arranging health care providers)
Physical = (household chores, transportation)
Personal = (bathing, eating, dressing, toileting, moving around (transfers), incontinence (bowels and bladder))
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