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Life Tasks Functioning Checklist

The following instrument is provided for free and unrestrained utilization as a service of Navik Solutions to behavioral health and health education professionals. The form is designed for use with adolescent and adult populations. The readability index is low. The items are positively stated and reduce inhibitions to completing the list. The materials are submitted as a template that can be modified for use in your practice.

Personal Habits
Task Seldom  Usually  Often Always N/A
Able to focus mentally
Sleep well
Have energy
Exercise 20 minutes 3 times a week
Positive attitude
Sense of humor
Seek personal goals
Keep regular hours

Score

0

Personal Hygiene
Task Seldom  Usually  Often Always N/A
Bathe
Hair
Clean clothes
Teeth cleaned
Nails, cut & clean
Clean clothes
Vacuum
Dust
Wash dishes
Take out garbage
Wash windows
Dust behind furniture

Score

0

Work (or school)
Task Seldom  Usually  Often Always N/A
Arrive on time
Put forth effort
Achieve results
Receive compliment from supervisor (or teacher)
Receive compliment from customer (or peer)
Receive positive performance appraisal (or grades)

Score

0

Family Relations
Task Seldom  Usually  Often Always N/A
Get along with immediate family
Get along with relatives
Trust relatives
Respect relatives

Score

0

Peer Relations
Task Seldom  Usually  Often Always N/A
Get along with friends
Trust friends
Respect friends
Use of Spare time
Active
Constructive
Learn
Help others

Score

0

When you have completed the questions, click submit.

 

You can chart your personal progress in each section over time. The higher the scores, the better you perceive your life is working.