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["生活状況を把握するためのアセスメントシート"]
[]
["利用者氏名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
["障害高齢者の\n日常生活自立度",null,null,null,null,null,"□","自立","□","J1","□","J2","□","A1","□","A2",null,"初回(黒):",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","記入者:"]
[null,null,null,null,null,null,"□","B1","□","B2","□","C1","□","C2",null,null,null,"2回目(赤):",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","記入者:"]
["認知症高齢者の\n日常生活自立度",null,null,null,null,null,"□","自立","□","Ⅰ","□","Ⅱa","□","Ⅱb",null,null,null,"3回目(青):",null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日","記入者:"]
[null,null,null,null,null,null,"□","Ⅲa","□","Ⅲb","□","Ⅳ","□","M"]
[]
["ご本人の主訴・意向\nこれからの生活についての希望"]
[]
["家族の主訴・意向"]
[]
["Ａ　活動面について：",null,null,null,null,null,null,null,null,null,"自ら行きたい場所に移動するための手段を取れるかどうか。乗り物を操作する、歩く、走る、昇降する、様々な交通を用いることによる移動を行えているかどうか。"]
[]
["アセスメント項目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課題・ニーズ等記載欄"]
["運動機能\n（支えの必要性）",null,null,null,null,null,null,"立ち上がり： ",null,null,null,"□","なし",null,null,"□","あり"]
[null,null,null,null,null,null,null,"片足立ち　：",null,null,null,"□","なし",null,null,"□","あり"]
["歩行状況\n（歩行レベル）",null,null,null,null,null,null,"室内",null,"□","自立",null,"□","杖",null,"□","歩行器",null,null,"□","手押し車"]
[null,null,null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"屋外",null,"□","自立",null,"□","杖",null,"□","歩行器",null,null,"□","手押し車"]
[null,null,null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["転倒傾向　",null,null,null,null,null,null,"転倒",null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,null,null,null,"（状況など：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"つまずき",null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,null,null,null,"状況など：(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["移動範囲　",null,null,null,null,null,null,"□","近隣中心",null,null,null,"□","区内",null,null,"□","市内",null,null,"□","市外も可"]
["移動手段",null,null,null,null,null,null,"□","電車",null,"□","バス",null,"□","タクシー",null,null,null,"□","自転車(",null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","車(",null,"□","運転",null,"□","同乗)",null,"□","徒歩",null,"□","その他(",null,null,null,null,null,")"]
["Ｂ　日常生活について：",null,null,null,null,null,null,null,null,null,"家事（買い物・調理・掃除・洗濯・ごみ捨て等）や、住居、経済の管理、花木やペットの世話などを行っているかどうかの状況。"]
[]
["アセスメント項目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課題・ニーズ等記載欄"]
["買い物",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["調理",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["洗濯・洗濯物干し",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["掃除",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["整理整頓・ごみ捨て",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["金銭管理\n（家計の管理）",null,null,null,null,null,null,"□","自分",null,"□","家族",null,"□","知人",null,"□","その他(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"状況",null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
["情報収集",null,null,null,null,null,null,"□","新聞",null,null,null,null,"□","テレビ・ラジオ",null,null,null,null,null,"□","人づて"]
[null,null,null,null,null,null,null,"□","近隣の広報",null,null,null,null,"□","インターネット",null,null,null,null,null,"□","関心がない"]
[null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["Ｃ　社会や人との\n　　関わりについて：",null,null,null,null,null,null,null,null,null,"状況に見合った社会的に適切な方法で、人々と交流しているか、また家族・近隣の人との人間関係が保たれているか。仕事やボランティア活動、老人クラブや町内会行事への参加の状況や家族内や近隣における役割の有無などの内容や程度はどうか"]
[]
[]
["アセスメント項目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課題・ニーズ等記載欄"]
["コミュニケーション",null,null,null,null,null,null,"□","自己の意思の表出ができる"]
[null,null,null,null,null,null,null,"□","他者の話の内容が理解できる"]
[null,null,null,null,null,null,null,"□","その他の状況(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"視力",null,null,"□","支障なし",null,null,null,null,"□","支障あり"]
[null,null,null,null,null,null,null,null,null,null,"その他の状況(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"聴力",null,null,"□","支障なし",null,null,null,null,"□","支障あり"]
[null,null,null,null,null,null,null,null,null,null,"その他の状況(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["社会参加",null,"活動性",null,null,null,null,"□","趣味や楽しみ、特技がある(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","仕事をしている"]
[null,null,null,null,null,null,null,"□","地域活動やボランティア活動に参加している"]
[null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","特にない"]
[null,null,"外出頻度",null,null,null,null,"□","ほぼ毎日",null,null,null,null,null,"□","週2～3回",null,null,null,null,null,"□","週1回程度"]
[null,null,null,null,null,null,null,"□","月2～3回",null,null,null,null,null,"□","殆ど外出しない"]
[null,null,"主な外出の\n目的",null,null,null,null,"□","趣味・楽しみ(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","仕事",null,null,null,"□","地域活動等への参加"]
[null,null,null,null,null,null,null,"□","買い物",null,null,null,"□","通院"]
[null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["対人関係",null,"家族・近隣\n友人・知人\nとの交流",null,null,null,null,"状況"]
[]
[]
[]
[]
["Ｄ　健康面について：",null,null,null,null,null,null,null,null,null,"清潔・整容と服薬・定期受診が行われているかどうか。また飲酒や喫煙のコントロール、食事や運動、休養など健康の自己管理の観点から必要と思われた場合、この領域でアセスメントする必要がある。（自己管理または家族による管理）"]
[]
[]
["アセスメント項目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課題・ニーズ等記載欄"]
["身長・体重",null,null,null,null,null,null,"身長",null,null,"(",null,null,null,null,null,null,")","cm"]
[null,null,null,null,null,null,null,"体重",null,null,"(",null,null,null,null,null,null,")","kg"]
["病気について",null,null,null,null,null,null,"病名",null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
[null,null,null,null,null,null,null,"既往歴",null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"病識",null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"かかりつけ医"]
[null,null,null,null,null,null,null,"病院・医院名",null,null,null,null,null,null,null,null,null,"担当医師名",null,null,null,null,null,"頻度"]
[null,null,null,null,null,null,null,"①","(",null,null,null,null,null,null,null,")","(",null,null,null,null,")",null,"回","／","月"]
[null,null,null,null,null,null,null,"②","(",null,null,null,null,null,null,null,")","(",null,null,null,null,")",null,"回","／","週"]
[null,null,null,null,null,null,null,"③","(",null,null,null,null,null,null,null,")","(",null,null,null,null,")",null,"回","／","週"]
["服薬管理",null,null,null,null,null,null,"服薬",null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,"薬の情報（種類・回数など）"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"服薬\n状況",null,null,"□","忘れず飲む",null,null,null,null,null,null,"□","よく忘れる"]
[null,null,null,null,null,null,null,null,null,null,"□","時々忘れる",null,null,null,null,null,null,"□","介助が必要"]
[null,null,null,null,null,null,null,"かかりつけ薬局(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["口腔・嚥下",null,null,null,null,null,null,"状態(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"歯科受診",null,null,"□","無",null,"□","有","かかりつけ医(",null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"義歯",null,null,"□","無",null,"□","有",null,"(","□","全義歯",null,null,"□","部分義歯",null,null,null,")"]
[null,null,null,null,null,null,null,"ケアの方法(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"嚥下",null,null,"□","支障なし",null,null,null,"□","支障あり(状況：",null,null,null,null,null,null,null,null,null,")"]
["食生活・栄養状況",null,null,null,null,null,null,"回　数：",null,null,"(",null,null,"回／日)"]
[null,null,null,null,null,null,null,"状　況：",null,null,"□","バランスに気をつけている",null,null,null,null,null,null,null,null,null,"□","偏りあり"]
[null,null,null,null,null,null,null,null,null,null,"□","制限あり",null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"食形態：",null,null,"□","普通食",null,null,"□","治療食",null,null,"□","その他(",null,null,null,null,null,null,")"]
["水分摂取状況",null,null,null,null,null,null,"□","気をつけている",null,null,null,null,null,null,null,"□","特に気をつけていない"]
[null,null,null,null,null,null,null,"１日の摂取量(",null,null,null,null,null,null,null,null,"ml )"]
[null,null,null,null,null,null,null,"制　限:",null,null,"□","無",null,"□","有",null,"制限量（",null,null,null,null,null,null,"ml )／日"]
["飲酒・喫煙状況",null,null,null,null,null,null,"飲　酒：",null,null,"□","無",null,"□","有",null,"□","やめた"]
[null,null,null,null,null,null,null,"頻　度：",null,null,"(",null,null,null,null,"回","／","週",")"]
[null,null,null,null,null,null,null,"量　：",null,null,"(",null,null,null,null,"／回)"]
[null,null,null,null,null,null,null,"喫　煙：",null,null,"□","無",null,"□","有",null,"□","やめた",null,null,"期間(",null,null,null,null,")年間"]
[null,null,null,null,null,null,null,"量　：",null,null,"(",null,null,null,null,"本","／","日",")"]
["適度な運動",null,null,null,null,null,null,"□","している(内容・頻度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","していない(理由：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["適度な休息",null,null,null,null,null,null,"□","心がけている",null,null,null,null,null,"□","つい無理をしてしまう"]
[null,null,null,null,null,null,null,"□","睡眠状況",null,null,null,"(起床：",null,null,null,null,"時","／","就寝：",null,null,null,null,null,"時)"]
["排泄の状況",null,null,null,null,null,null,"排便(",null,null,null,"／","日",")",null,"排尿(",null,null,null,"回／日)"]
[null,null,null,null,null,null,null,"□","支障なし",null,null,null,"□","尿漏れ・尿失禁がある"]
[null,null,null,null,null,null,null,"□","紙パンツ",null,null,null,"□","紙パット",null,null,null,"□","ポータブルトイレ"]
["入浴の状況",null,null,null,null,null,null,"頻度(",null,null,null,"／","週",")"]
[null,null,null,null,null,null,null,"□","入浴",null,"□","シャワー",null,null,null,"□","清拭",null,null,"□","介助が必要"]
["アレルギー",null,null,null,null,null,null,"□","無",null,"□","有",null,"□","不明"]
[null,null,null,null,null,null,null,"食品・薬品名など(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["感染症",null,null,null,null,null,null,"□","無",null,"□","有",null,"□","不明"]
[null,null,null,null,null,null,null,"種類(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["物忘れの状況",null,null,null,null,null,null,"□","無",null,"□","有","(",null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["E　その他：",null,null,null,null,null,null,null,null,null,"生活状況全体を理解するために必要な項目を、聞き取りや観察から、ここでアセスメントする。"]
[]
["アセスメント項目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"課題・ニーズ等記載欄"]
["住居環境",null,null,null,null,null,null,"□","持ち家",null,null,"□","借家"]
[null,null,null,null,null,null,null,"□","戸建て",null,null,"□","集合住宅(",null,null,null,null,null,")階　(エレベーター",null,null,null,null,null,null,"　",")"]
["居住状況（屋内外）",null,null,null,null,null,null,"手すり",null,null,null,"□","無",null,"□","有","(",null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"段差",null,null,null,"□","無",null,"□","有","(",null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"トイレ",null,null,null,"□","和式",null,"□","洋式"]
[null,null,null,null,null,null,null,"ﾍﾞｯﾄﾞの使用",null,null,null,"□","無",null,"□","有","(種類：",null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["経済状況",null,null,null,null,null,null,"収入",null,null,"(",null,null,"万円／",null,null,"月",")主な使途(",null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"介護保険負担割合",null,null,null,null,null,"(",null,null,")割"]
[null,null,null,null,null,null,null,"心配なこと(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"年　金",null,null,"□","国民年金",null,null,null,"□","厚生年金",null,null,null,"□","障害年金"]
[null,null,null,null,null,null,null,null,null,null,"その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"生活保護受給",null,null,null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,"介護に費やせる予算",null,null,null,null,null,null,null,"(",null,null,null,null,")円／月"]
["家族について",null,null,null,null,null,null,"ジェノグラム",null,null,null,null,null,null,null,null,null,null,null,null,"キーパーソン"]
[]
[]
[]
[]
[]
["家族の状況"]
[]
["精神的な不安\n意欲低下",null,null,null,null,null,null,"□","無",null,"(内容：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","有"]
["見守りの状況",null,null,null,null,null,null,"□","無",null,"□","有"]
[null,null,null,null,null,null,null,"□","家族(",null,null,null,null,null,null,")","□","民生委員など",null,null,null,"(",null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","隣人・知人(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","ICT見守り(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","その他(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
["近隣の協力者"]
[]
["緊急時の\nSOSの発信",null,null,null,null,null,null,"□","自分なりの対応ができる",null,null,null,null,null,null,null,null,null,null,"□","自信がない"]
[null,null,null,null,null,null,null,"□","特に考えていない"]
[null,null,null,null,null,null,null,"緊急性の判断：",null,null,null,null,null,"□","できる",null,null,null,null,"□","できにくい"]
["生活史\n（生育歴・学歴・\n職歴・嗜好など）"]
[]
[]
[]
[]
[]
["１日の目標",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1年の目標"]
[]
["インフォーマルサービス\n自ら取り組んでいること"]
[]
[]
["1日の過ごし方"]
[null,null,null,null,null,null,null,null,5,null,6,null,7,null,8,null,9,null,10,null,11,null,12,null,14,null,16,null,18,null,20,null,22,null,24]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["主な週間予定",null,null,null,null,null,null,"月"]
[]
[null,null,null,null,null,null,null,"火"]
[]
[null,null,null,null,null,null,null,"水"]
[]
[null,null,null,null,null,null,null,"木"]
[]
[null,null,null,null,null,null,null,"金"]
[]
[null,null,null,null,null,null,null,"土"]
[]
[null,null,null,null,null,null,null,"日"]
[]
["備考欄"]