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WE SERVE: Douglas, Forsyth, Cobb, Dekalb, Clayton, Gwinnett, Fulton

Premier Provider of Non-Medical Home Care in the Atlanta Area

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Resident Name

Caregiver Name

Today's Date

Month

Day

Year

Section 1: Activities of Daily Living (ADLs). Select all activities you assisted the resident with today.

Bathing

Dressing

Oral Care

Toileting

Mobility

Eating

Medication

Additional infomation

Section 3: Caregiver Tasks*

Monitoring For Memory Care/alzheimer's

Meal Prep ☐ Breakfast ☐ Lunch ☐ Dinner ☐

Bathroom/ toileting Assistance

Housekeeping ☐ Dishes ☐ Laundry ☐ Tidying ☐

Exercises/Therapy ☐ Type: _______________________

Appointments ☐ Doctor ☐ Therapy ☐ Other: ____

Safety Checks ☐ Fall risks ☐ Home hazards ☐

Other

Any questions or concerns?

Client/ Family Member Signature*

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Make sure A Client or A family member sign Here

LILBURN

30047

866-753-1359

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