Sample
TLC Senior Care
Respite / Personal Care
____ Feed Client ____ Prepare Meals ____ Serve Meals ____ Bed Bath : Complete
____ Bed Bath : Partial ____ Tub Bath ____ Shower : Standing : Sitting ____ Dental Care
____ Skin Care ____ Shave ____ Shampoo ____ Comb/Brush Hair____ Oral Hygiene
____ Nails ____ Assist with Dressing____ Assist with Toileting ____ Turn and Position
____ Exercise/Range of Motion ____ Assist with Walking ____ Assist with Transfer
____ Bed Assistance ____ Medications____ Companionship
____Medical Appointments ____ Pain Chart # 1-10
Blood Pressure - Glucose Testing
AM Noon PM
______ _____ _____
BM ____________Urine___________
Homemaking Activities
____ Vacuuming ____ Dusting____ Make Bed____ Empty Trash ____ Errands
____ Change Linen ____ Wash Linens/Clothes ____ Clean Bathrooms
____ Grocery Shopping ____ Clean Refrigerator ____ Clean Kitchen
____ Wash Dishes ____ Prepare Meals ____ Other (Custom to your needs)
Notes: We note in 30 and 60 minute increments for the time we are there.
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