Frequency Activities
Sun
Mon
Tues
Wed
Thu
Fri
Sat
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist - Daily Walk
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist- Exercises
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist- Stand Only
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist - Unsteady - Fall Risk
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Outside Activites With Assist
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Transfer Bed/Chair
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Postitioning
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Other:
Frequency Diet/Meal Preparation
Sun
Mon
Tues
Wed
Thu
Fri
Sat
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Breakfast
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Lunch
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Dinner
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Other:
Frequency Medication Reminders
Sun
Mon
Tues
Wed
Thu
Fri
Sat
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week
Medications are set-up by: Select One Family Client Friend Nurse Pharmacist
Frequency Personal Care
Sun
Mon
Tues
Wed
Thu
Fri
Sat
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Oxygen - Hygiene Care Only
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist Bathing - Bed Bath
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist Bathing - Shower
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist - Dressing
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist - Feeding
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Assist - Toileting
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Dust
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Change Bed Linens
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Clean Bathrooms
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Grocery Shopping
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Laundry
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Mouth Care
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Skin Care
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Take To Appointments
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Tidy Up
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Vaccuum
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Shampoo, Comb/Brush Hair
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Wash Dishes
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Shaving
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Ostomy Care-Emptying Only
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Support Stockings -Only If Not Prescribed by a Doctor
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Foley Catherter Care - Emptying Only
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Other:
Select One Daily As Needed AMS PMs Nights 1 x Day 2 x Day 3 x Day 1 x Week 2 x Week 3 x Week Other:
Caregiver Recommendations:
Caregiver Notes:
