Customer’s Visit Survey

Your Name (required)

Date (Required)

Customer's Name (Required)

PLEASE ANSWER THE QUESTIONS BELOW IN REGARDS TO TODAY'S VISIT.

Dressing & Grooming

Dress yourself, including shoelaces and buttons? Shampoo your hair?
YesWith some difficultNo

Shampoo your hair?
YesWith some difficultNo

Arising

Stand up from a chair?
YesWith some difficultNo

Get in and out of bed?
YesWith some difficultNo

Eating

Cut your own meat?
YesWith some difficultNo

Lift a full cup or glass to your mouth?
YesWith some difficultNo

Open a new milk carton?
YesWith some difficultNo

PLEASE CHECK ANY AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THE ABOVE ACTIVITIES:

Devices used for DressingSpecial or built up chairBuilt up or special utensilsCaneWalkerCrutchesWheelchairCPNP

PLEASE CHECK ANY AIDS OR DEVICES THAT YOU USUALLY USE FOR ANY OF THE ABOVE ACTIVITIES:

Raised toilet seatBathtub seatBathtub barAppliances in bathroomLong-handled appliancesJar opener

PLEASE CHECK ANY CATEGORIES FOR WHICH THE PATIENT USUALLY NEED HELP FROM ANOTHER PERSON:

EatRestroomHygieneReachGripping and Opening thingsGymErrands and choresDrivingPlay Dominoes,Play CardsFishingListening Music

DAILY CHECKLIST

Make bed/Get DressedEat/Brush TeethReligion/Spiritual ReadingMathReadingWriting/Handwriting PracticeGrammarSpellingScience/HealthHistory/GeographyPhysical Education/SportsArtsMusicForeign LanguagePerforming ArtsComputer SkillsChess/Strategy GamesChoresPick up things before bedPajamas/Brush Teet /Drink