DAILY LOG CHECKOFF

WHAT DAY NIGHT MOBILITY AIDS USED TODAY INCLUDE: WOKE UP: SLEEP NOTES
MEDICATION BEDTIME:
MEDICATION
MEDICATION TIMES WOKEN BY:
MEDICATION YN URINE COLOR: 01234567+ PET 1 2 3 4 5 +
MEDICATION Y N EXCREMENT BRISTOL TYPE: 01234567+ PARTNER 1 2 3 4 5 +
VITAMIN PEE/POO 1 2 3 4 5 +
VITAMIN MED NOTES: CHANGES? NAUSEA 1 2 3 4 5 +
VITAMIN [Y] [N] [NEED] VOMIT 1 2 3 4 5 +
SUPPLEMENT PAIN 1 2 3 4 5 +
SUPPLEMENT
SUPPLEMENT MOVEMENT NOTES: CHANGES? AID NEEDED TO FALL ASLEEP
OUTSIDE TIME [Y] [N] [NEED] [Y] [N] WRITE TYPE(S) BELOW
EXERCISE
PHYSIO

LOW MOD HIGH SOS MEDS? INDEPENDENT NEEDS HELP DEPENDENT DOES NOT DO
NAUSEA BATHING
VOMITING DRESSING
DEPRESSION GROOMING
ANXIETY ORAL CARE
PANIC TOILETING
TRANSFERRING
PAIN: AM WALKING
PAIN: NOON CLIMBING STAIRS
PAIN: EVENING EATING
PAIN: NIGHT SHOPPING
COOKING
MOBILITY MANAGING MEDICATIONS
SOCIAL DESIRE USING THE PHONE
SOCIAL ACTUAL HOUSEWORK
DOING LAUNDRY
SLEEP QUALITY DRIVING
SLEEP QUANTITY MANAGING FINANCES

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