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

Dressing & Grooming


YesWith some difficultNo


YesWith some difficultNo

Arising


YesWith some difficultNo


YesWith some difficultNo

Eating


YesWith some difficultNo


YesWith some difficultNo


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