DCL - Activity Log

Daily Activity Log

Date of Service *

Patient's Name *

Caregiver Name *

Start Date *

Start Time *

End Date *

End Time *

Bathing *

Eating ( Feeding - Supervision ) *

Getting Dressed *

Bathroom / Toileting *

Incontinence Care *

Transferring *

Personal Hygiene *

Moving About ( e.g. from bed to bathroom ) *

Walking *

Going Up Stairs *

Notes

0/780

Safety Supervision *

Housekeeping / Light Cleaning *

Laundry *

Medication Reminder, AM Time *

Medication Reminder, PM Time *

Transportation *

Exercise / Stretching *

Appointments / Events *

Meal Preparation *

Shopping *

Money Management *

Care Needs / Homemaker Service Notes

0/780

I declare that all the above information is complete and true. I hereby certify that I performed all services indicated as stated.

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