Functional Changes Checklist

This checklist represents functional changes in the ability to complete activities of daily living. Check all that apply. You are encouraged to share this information with a medical provider to determine any underlying causes or conditions for the changes.

Appointments:

• ______ individual is not able to use a calendar to record upcoming appointments
• ______ individual is missing appointments without calling to cancel or re-schedule
• ______ individual does not remember who their doctor, dentist, barber, etc. is.
• ______ individual has difficulty scheduling appointments by phone or online
• ______ individual is no longer considered safe to drive to appointments
• ______ individual is getting lost on their way to appointments or other destinations

Clothing:

• ______ individual is not keeping up with laundry (clothing/linens) on regular basis
• ______ individual is wearing clothing that is dirty, in poor condition or inappropriate for an event, season, etc.
• ______ individual is wearing the same clothing every day
• ______ individual is purchasing clothing that is not appropriate, too expensive or in the wrong size
• ______ individual is having difficulty with buttons, zippers and/or other fasteners

Environment:

• ______ individual has unopened mail and/or magazines, newspapers, etc. piling up
• ______ individual has increased clutter including trash
• ______ individual is not keeping up with general cleaning, maintenance, etc.
• ______ individual is not setting appropriate temperatures
• ______ individual is leaving appliances on or open
• ______ individual is confused as to how to operate tv remote, appliances, etc.

Finances:

• ______ individual is not cashing/depositing checks
• ______ individual has multiple unpaid bills
• ______ individual is giving money to causes/organizations or people not previously supported
• ______ individual is not tracking expenses/accounts
• ______ individual is purchasing unnecessary items
• ______ individual is unable to recognize coins and/or bills

Hygiene:

• ______ individual is not bathing/washing on a regular basis
• ______ individual is wearing soiled clothing
• ______ individual is not caring for their teeth
• ______ individual is not shaving, receiving haircuts, trimming excess hair
• ______ individual has dirty or excessively long finger/toenails

Medication:

• ______ individual is not taking medication as prescribed/scheduled
• ______ individual is not having prescriptions filled in a timely manner
• ______ individual is refusing medication
• ______ individual is taking someone else's medication
• ______ individual is taking expired medication

Cognitive/Communication:

• ______ individual is misplacing keys, wallets, phone, etc. with increased frequency
• ______ individual is forgetting the names of people they have known a long time
• ______ individual is repeating “stories” or asking the same questions over and over
• ______ individual is having increased difficulty “finding” words during conversation
• ______ individual is having increased difficulty understanding questions or following directions