English: REQUIREMENTS PROBLEMS ASSESSMENT FACTORS NORMAL ______________________________________________________________________________________________ Care compliance ______________________________________________________________________________________________ Problem solving ______________________________________________________________________________________________ Family supports ______________________________________________________________________________________________ Mental stability ______________________________________________________________________________________________ Mental orientation ______________________________________________________________________________________________ Mood ______________________________________________________________________________________________ Motivation ______________________________________________________________________________________________ Judgement ______________________________________________________________________________________________ Safety at risk ______________________________________________________________________________________________ Space adequacy ______________________________________________________________________________________________ Household cleaning ______________________________________________________________________________________________ Water available ______________________________________________________________________________________________ Heating ______________________________________________________________________________________________ Waste disposal ______________________________________________________________________________________________ Home repairs ______________________________________________________________________________________________ Home modifications ______________________________________________________________________________________________ Yard care ______________________________________________________________________________________________ Refrigeration ______________________________________________________________________________________________ Laundry ______________________________________________________________________________________________ Clothes drying ______________________________________________________________________________________________ Toilet ______________________________________________________________________________________________ Bathtub/shower ______________________________________________________________________________________________ Manages own affairs ______________________________________________________________________________________________ Ministers own meds ______________________________________________________________________________________________ Manages own treatment ______________________________________________________________________________________________ Spiritual health ______________________________________________________________________________________________ Financial situation ______________________________________________________________________________________________ Community support ______________________________________________________________________________________________ Helpful friend(s) ______________________________________________________________________________________________ APPENDIX E - SAMPLE 2
French: ______________________________________________________________________________________________ CRITÈRES D’ÉVALUATION RÉGULIER PROBLÈMES EXIGENCES ______________________________________________________________________________________________ Observance thérapeutique ______________________________________________________________________________________________ Résolution de problèmes ______________________________________________________________________________________________ Soutien de la famille ______________________________________________________________________________________________ Stabilité psychologique ______________________________________________________________________________________________ Orientation psychologique ______________________________________________________________________________________________ Humeur ______________________________________________________________________________________________ Motivation ______________________________________________________________________________________________ Jugement ______________________________________________________________________________________________ Sécurité à risque ______________________________________________________________________________________________ Milieu de vie adéquat ______________________________________________________________________________________________ Entretien ménager ______________________________________________________________________________________________ Eau disponible ______________________________________________________________________________________________ Chauffage ______________________________________________________________________________________________ Évacuation des ordures ______________________________________________________________________________________________ Réparation du domicile ______________________________________________________________________________________________ Modification du domicile ______________________________________________________________________________________________ Entretien de la cour ______________________________________________________________________________________________ Réfrigération ______________________________________________________________________________________________ Lessive ______________________________________________________________________________________________ Séchage des vêtements ______________________________________________________________________________________________ Soins de toilette ______________________________________________________________________________________________ Bain et douche ______________________________________________________________________________________________ Gestion des affaires personnelles ______________________________________________________________________________________________ Prise de médicaments ______________________________________________________________________________________________ autonome Traitement autonome ______________________________________________________________________________________________ Santé spirituelle ______________________________________________________________________________________________ Situation financière ______________________________________________________________________________________________ Soutien communautaire ______________________________________________________________________________________________ Aide des amis ______________________________________________________________________________________________ ANNEXE E - EXEMPLE 2