The Horizons Private Duty Care Life Activities Evaluation form provides insight into the level of assistance that a senior loved one may require. It is simple to use and may be completed online and then printed for your reference.
NOTE: This form is in PDF format and requires Adobe Reader software for viewing and printing. If you do not already have the reader software, you may download it by clicking here.
To complete the form, click below to open a new window with the Life Activities Evaluation form. For each listed activity, check the box that most closely represents the ability level of the loved one being evaluated. Use the completed evaluation as a starting point when considering how best to provide your loved one with the assistance he/she requires to stay safe and secure. Complete the form online and then click print on the form to print a copy.