Medication Self-Directed Evaluation Tool
Client Name: _______________________________________
Date: _________________
When asked to provide assistance in medication assistance, this form MUST be completed with
the client to determine the appropriateness of:



Medication Reminders
Medication Assistance
Medication Management
Ask the Client the following questions:
Yes
No
Can you tell me what medications you are taking?
Yes
No
Can you tell me how much of the medication you’re supposed to take?
Yes
No
Can you tell me what route the medication should be taken?
Yes
No
Can you tell me why you are taking the medication?
Yes
No
Can you tell me what time or how often you take the medication?
Medication
Reason
Frequency Verified
Determination:
Revised 04/15/2022
Page 1 of 2
Medication Self-Directed Evaluation Tool
Medication Administration Required
Notes:
Medication Assistance
Medication Reminder
Able to self-Administer Medications *If Checked, the Client must attest to the authenticity of
the information provided and must sign below.
_____________________________________________
Senior Helpers Representative
_______________
Date:
I agree with the information documented above and acknowledge that I understand what medications
I am taking, why I am taking the medications and when I am supposed to take the medications.
_____________________________________________
Client Name:
_____________________________________________
Client Signature:
_______________
Date:
Family or Friend will manage all medications:
_____________________________________________
Name of person responsible for the medications:
_____________________________________________
Signature of the person responsible for the medications:
_______________
Date:
Revised 04/15/2022
Page 2 of 2