Dedicated Care Living Activity Log
Date of Services
Patient's Name
Caregiver Name
Caregiver Email
Patient Address
Patient Email
Patient Birthdate
Patient Contact No.
Insurance Provider
Policy #
Start Date
Start Time
End Date
End Time
Activities of Daily Living (Bathing)
N/A
No Help
Total Help
Needs Help
Standby
Eating ( Feeding - Supervision)
N/A
No Help
Total Help
Needs Help
Standby
Getting Dressed
N/A
No Help
Total Help
Needs Help
Standby
Bathroom / Toileting
N/A
No Help
Total Help
Needs Help
Standby
Incontinence Care
N/A
No Help
Total Help
Needs Help
Standby
Transferring
N/A
No Help
Total Help
Needs Help
Standby
Personal Hygiene
N/A
No Help
Total Help
Needs Help
Standby
Moving About ( e.g. from bed to bathroom )
N/A
No Help
Total Help
Needs Help
Standby
Walking
N/A
No Help
Total Help
Needs Help
Standby
Going Up Stairs
N/A
No Help
Total Help
Needs Help
Standby
Notes
Care Needs / Homemaker Services (Safety Supervision)
No
Yes
House Keeping / Light Cleaning
No
Yes
Laundry
No
Yes
Medication Reminder, AM Time
No
Yes
Medication Reminder, PM Time
No
Yes
Transportation
No
Yes
Exercise / Stretching
No
Yes
Appointments / Events
No
Yes
Meal Preparation
No
Yes
Shopping
No
Yes
Money Management
No
Yes
Care Needs / Homemaker Service Notes
I declare that all the above information is compleate and true. I hereby certify that I performed all services indicated as stated.
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