Caregiver name:

Date Hours today

Hours for entire week (Enter each Friday)

Items checked

• Medicine box: have meds been taken since last visit? Yes No

• General condition: any new injuries, illnesses, problems? Yes No
If yes, explain:

Activities Check all that apply

Cooked meal    Fed Poker   Cleaned around the house     Cleaned up after dog in garage   
Went for a walk on the property.   Trimmed toenails     Filled medicine box
Other:

Transportation Drove to (check all that apply)

Grocery store      Physical Therapy     Doctor     Haircut     Bank

Other:

Appointments

Did you schedule any new appointments for Dad while you were there? If yes, please let us know with whom and when:

Any other notes, observations or concerns? Please tell us anything that would help.