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Expert Care Advice
Client Name
*
Date of Birth
Address
Emergency Contact
Relationship
Phone
Start Date
Care Plan Review Date
Multi choice
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours of Service
Care Needs Summary
Personal Care
*
Bathing Assistance
Grooming
Dressing
Toileting Assistance
Other
Companionship Needs
Conversation
Activities
Supervision
Other
Meal Support
Meal Preparation
Feeding Assistance
Grocery Assistance
Other
Household Support
Light Housekeeping
Laundry
Organization
Other
Transportation
Medical Appointments
Errands
Social Activities
Other
Medication Reminders?
Preferred Caregiver Gender
Language Preference
Special Requests
Safety & Risk Factors
Fall Risk
Mobility Issues
Memory/Cognitive Issues
Requires Supervision
Other
Safety Instructions
Home Environment
Pets in Home
Smoking in home
Security Consideration
Other
Care Instructions (important)
Restrictions (do not perform)
Supervisor Notes
Client/Responsible Party Signature (type name)
Signature Date
Supervisor Name
Supervisor Signature (type name)
Supervisor Signature Date
Next Review Date
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