Activity sheets must reach our office by 5pm every Wednesday for processing.

Clients Name (Last, First)
Home Health Aides Name

	SUN	MON	TUE	WED	THUR	FRI	SAT
DATE
TIME STARTED
TIME ENDED
TOTAL DAILY HOURS
ERRAND MILES

CLIENT SIGNATURE: Please verify information before signing.					TOTAL WEEKLY HOURS
CHHA SIGNATURE:					DATE:

DAILY ACTIVITIES	SUN	MON	TUE	WED	THUR	FRI	SAT
1. POSITIONING A.Up as tolerated B.T&P every 2 hours	A B	A B	A B	A B	A B	A B	A B
2. BATHING A.Shower B.Sponge C.Bed Bath D.Chair	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
3. HAIR CARE A.Shampoo B.Shower C.Bed D.Groom	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
4. MOUTH CARE A.Denture B.Brush Teeth C.Rinse	A B C	A B C	A B C	A B C	A B C	A B C	A B C
5. SKIN CARE A.Lotion B.Nail care C.Shave	A B C	A B C	A B C	A B C	A B C	A B C	A B C
6. DRESSING A.Assist B.Complete C.Day D.Evening	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
7. AMBULATION A.Walking B.Cane C.Walker D.Wheelchair	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
8. ROM A.Active B.Passive C.Elevate	A B C	A B C	A B C	A B C	A B C	A B C	A B C
9. TRANSFER A.Bed to chair B.Hoyer Lift C.Pivot	A B C	A B C	A B C	A B C	A B C	A B C	A B C
10. DIET A.Fluids B.Encourage C.Restrict D.Regular E.Low Salt F.Low Fat G.Diabetic H.Other	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H
11. MEAL PREP A.Breakfast B.Lunch C.Dinner D.Feed E.Cut F.Supervise	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F
12. MEDICATIONS A.Remind Medications	A	A	A	A	A	A	A
13. ELIMINATION A.Toilet B.Commode C.Bed Pan D.Measure E.Catheter F.Depends/pads	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F
14. LIGHT HOUSEKEEPING A.Bedroom B.Bathroom C.Kitchen D.Make Bed Linen Change E.Laundry	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E
15. SHOPPING
16. PAIN MANAGEMENT (0-10)
16. OTHER DUTIES

ANY CHANGE IN PATIENT STATUS, CONTACT RN IMMEDIATELY.

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