| Personal
Care |
| • |
Bathing/Grooming: |
_______________________________________________________ |
| • |
Feeding: |
_______________________________________________________ |
| • |
Dressing: |
_______________________________________________________ |
| • |
Toileting: |
_______________________________________________________ |
| • |
Exercise/Physical
Therapy: |
_______________________________________________________ |
| • |
Other: |
_______________________________________________________ |
|
|
|
| Daily
Activities/Maintaining the Household |
| • |
Shopping: |
_______________________________________________________ |
| • |
Cleaning: |
_______________________________________________________
|
| • |
Cooking: |
_______________________________________________________ |
| • |
Laundry: |
_______________________________________________________ |
| • |
Going
to Appointments: |
_______________________________________________________ |
| • |
Doing/Taking
Patient to Do Errands: |
_______________________________________________________ |
| • |
Other: |
_______________________________________________________ |
|
|
|
| Participating
in Medical/Nursing Care at Home |
| • |
Administering
Medications: |
_______________________________________________________ |
| • |
Performing
Medical Procedures (e.g. changing dressings): |
_______________________________________________________ |
| • |
Communicating
with the Health Care Team: |
_______________________________________________________ |
| • |
Symptom
Management (e.g. pain, breathlessness): |
_______________________________________________________ |
| • |
Other: |
_______________________________________________________ |
|
|
_______________________________________________________ |
| Supervision
|
| • |
Visiting: |
_______________________________________________________ |
| • |
Providing
Emotional Support: |
_______________________________________________________ |
| • |
Providing
Companionship: |
_______________________________________________________ |
| • |
Checking
on the Patient: |
_______________________________________________________ |
| • |
Other:
|
_______________________________________________________ |
| |
|
|
| Organizing
Home Care |
|
| • |
Visiting
Nurse: |
_______________________________________________________ |
| • |
Home
Care: |
_______________________________________________________ |
| • |
Hospice
Home Care: |
_______________________________________________________ |
| • |
Physical
Therapy: |
_______________________________________________________ |
| • |
Ordering
Equipment: |
_______________________________________________________ |
| • |
Other: |
_______________________________________________________ |
|
|
|
| Organizing
Medical Care |
|
| • |
Keeping
Track of Appointments: |
_______________________________________________________ |
| • |
Picking
Up Prescriptions: |
_______________________________________________________ |
| • |
Transportation
to Appointments: |
_______________________________________________________ |
| • |
Acting
as a Health Care Proxy: |
_______________________________________________________ |
| • |
Dealing with Emergency Hospital Visits: |
_______________________________________________________ |
| • |
Managing
Deliveries of Supplies/Equipment: |
_______________________________________________________ |
| • |
Other: |
_______________________________________________________ |
|
|
|
| Managing
Finances |
|
| • |
Handling
Insurance: |
_______________________________________________________ |
| • |
Maintaining
Bank Account: |
_______________________________________________________ |
| • |
Collecting Social Security Benefits: |
_______________________________________________________ |
| • |
Paying
Bills: |
_______________________________________________________ |
| • |
Paying
for Items Not Covered by Insurance: |
_______________________________________________________ |
| • |
Will
& Estate Planning: |
_______________________________________________________ |
| • |
Other:
|
_______________________________________________________ |
|
|
_______________________________________________________ |
| Other
|
|
|
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
|
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