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Task Description
Frequency
Level of Assistance
Special Training/Equipment
Priority
Notes
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---ADLs / IADLs---
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Bathing / Grooming
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Dressing
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Toileting
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Mobility / Transfers
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Eating / Meal Prep
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Medication Reminders
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Housekeeping
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Laundry
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Shopping / Errands
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---Health & Safety---
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Fall Risk
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Memory Issues
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Wandering Risk
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Special Diet
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Allergies
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Monitoring Needed (e.g., vitals, diabetes)
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Behavior / Mood Concerns
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---Equipment & Environment---
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Wheelchair / Walker / Cane
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Hoyer Lift
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Shower Chair / Grab Bars
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Oxygen / Nebulizer
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Other Equipment / Home Safety Concerns
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---Caregiver Support---
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Current Caregiver(s) & Hours
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Backup Caregiver?
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Respite Needed?
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Most Challenging Tasks
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---Priorities & Goals---
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Client Top 3 Goals
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Family Top 3 Concerns
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Preferred Schedule for Care
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