My Day Begins at: _______________

The tasks I need help with are as follows:

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The best time of the day for me is: ________________________________________________________

The most difficult time of the day for me is: ___________________________________________________

I usally end my day around: ________

Morning or afternoon naps: ___________________________________________________________________________________________

The following are tasks I need help with:

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Meals:

Breakfast:

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Lunch:

____________________________________________________________________________

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Dinner:

____________________________________________________________________________

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_____________________________________________________________________________

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My favorite beverage is: ___________________

I like my cofee or tea prepared: ___________________________________________________________

I also enjoy: _____________________________________________________________________

Special dietary needs:

____________________________________________________________________________

Special utensils: _____________________________________________________________

Foods I am allergic or sensitive to are:

____________________________________________________________________________

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Foods I don't like are:

____________________________________________________________________________

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My favorite food preferences are:

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I enjoy eating my meals served in (room): _________________________________________________

I enjoy having my caregiver eat with me: Yes ___No ___

My favorite restaurants (and you may order out from them) are:

Name: _______________________

Address: _____________________________________

Name: _______________________

Address: _______________________________________

Name: _______________________

Address: _______________________________________

Name: _______________________

Address: _______________________________________

For list of family, personal contacts, physicians and other professionals, please read our
emergency information list.

Things I need help with (please describe):

Keeping Clean and presentable: __________________________________________________________

Toileting: ______________________________________________________________________

Bathing: _______________________________________________________________________

Walking: _______________________________________________________________________

Climbing Steps: ___________________________________________________________________

Getting in and out of bed: ______________________________________________________________

Housework: _____________________________________________________________________

Making and receiving phone calls: _________________________________________________________

Walking: _______________________________________________________________________

Taking medications: _________________________________________________________________

Transportation (I use a medical//handicapped vehicle, a service or private car) :

____________________________________________________________________________

Shopping: ______________________________________________________________________

Eating: ________________________________________________________________________ _____________

Cooking: _______________________________________________________________________

I am most comfortable wearing: ___________________________________________________________

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Going out to an appointment I like to wear:

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Going out on an errand I like to wear:

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While in my home I like to wear:

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Going to church or temple I like to wear:

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Special appliances, health care items, or aids I use:

Wig: ____________________ Makeup: ____________________ Cane: ________________

Walker: ________________ Urinal/Bedpan: _______________ Commode: _____________

Wheelchair: ________________ Mobile chair (cart) : _________ Oxygen: ____________

Incontinence pads / adult diapers: ______________ Eyeglasses: ____________________

Contacts: _____________ Hearing Aid: _________________ Dentures: _______________

Special shoes, socks, etc.:___________________________________________________

Other:_____________________________________________________________________

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Problems with vision:

___________________________________________________________________________________________________________________

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Problems with hearing:

___________________________________________________________________________________________________________________

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Porblems with communication or memory:

___________________________________________________________________________________________________________________

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Problems with behavior (aggressiveness, destrutiveness, anger)

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I am right handed ________________ I am left handed  ________________________

Interests and Preferences (describe fully) :________

Crafts and hobbies	.
Television Programs	.
Radio Programs	.
Music	.
Exercise	.
Musical Instruments played	.
Languages spoken	.
Favorite topics for conversations	.
Meaningful life experiences	.
Travel experiences	.
Memorable childhood experiences	.
Marriage	.
Family	.
Religous & Spiritual background	.
Accomplishments	.
Other interests	.

I am involved in the following community programs:

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My disposition:

Caregivers enjoy caring for me because:

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Caregivers have difficulty with me because:

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Medication Schedule (note as much detail, difficulty swallowing, special needs)
Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,

Name of medication or vitamin	,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc.	.
Dosage	.
Times given:	_____times per day at _____________________________________________
Taken with fluid, after food or before eating	,
Special instructions	,