Activities of Daily Living (ADL) Assessment Form
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Activities of Daily Living (ADL) Assessment Form
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The Activities of Daily Living (ADL) Assessment Form provides a standardized evaluation of a patient's ability to independently perform essential self-care tasks and instrumental activities required for community living. Based on the Katz Index of Independence in ADL and the Lawton IADL Scale, this form rates patient functional status across basic ADLs including bathing, dressing, toileting, transferring, continence, and feeding, as well as instrumental ADLs such as medication management, financial handling, transportation, housekeeping, and meal preparation.
Each activity is rated on a structured independence scale ranging from fully independent to fully dependent, with intermediate levels capturing the need for supervision, minimal assistance, or maximum assistance. The form documents current assistive devices in use, environmental modifications in the home, and the availability of caregiving support. This detailed functional profile enables care teams to identify specific areas where intervention, adaptive equipment, or additional support services may improve patient independence and safety.
Widely used in geriatric medicine, home health agencies, skilled nursing facilities, rehabilitation programs, and social work assessments, this form supports care planning, discharge readiness evaluation, level-of-care determinations, and caregiver education. Regular ADL reassessment tracks functional trajectory over time, helping providers detect early decline and implement preventive strategies.
What's included
- Basic ADL assessment (bathing, dressing, toileting, transferring, feeding)
- Instrumental ADL evaluation (medications, meals, finances, transport)
- Independence rating scale from fully independent to fully dependent
- Assistive device and home modification documentation
- Caregiver availability and support assessment
- Functional trajectory tracking for serial reassessments
Who uses this template
- Geriatric functional status evaluation at annual wellness visits
- Hospital discharge planning and level-of-care determination
- Home health initial assessment and plan of care development
- Skilled nursing facility admission functional baseline
All form fields
14 fields across 2 pages. Customize any field after signing up.
How to use the Activities of Daily Living (ADL) Assessment Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Activities of Daily Living (ADL) Assessment Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Activities of Daily Living (ADL) Assessment Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Activities of Daily Living (ADL) Assessment Form HIPAA compliant?
Yes. All Formisoft templates, including the Activities of Daily Living (ADL) Assessment Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Activities of Daily Living (ADL) Assessment Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
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