List of Patient
Needs
| Personal Care | ||
| • | Bathing/Grooming: | _______________________________________________________ |
| • | Feeding: | _______________________________________________________ |
| • | Dressing: | _______________________________________________________ |
| • | Toileting: | _______________________________________________________ |
| • | Exercise/Physical Therapy: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| Daily Activities/Maintaining the Household | ||
| • | Shopping: | _______________________________________________________ |
| • | Cleaning: | _______________________________________________________ |
| • | Cooking: | _______________________________________________________ |
| • | Laundry: | _______________________________________________________ |
| • | Going to Appointments: | _______________________________________________________ |
| • | Doing/Taking Patient to Do Errands: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| Participating in Medical/Nursing Care at Home | ||
| • | Administering Medications: | _______________________________________________________ |
| • | Performing Medical Procedures (e.g. changing dressings): | _______________________________________________________ |
| • | Communicating with the Health Care Team: | _______________________________________________________ |
| • | Symptom Management (e.g. pain, breathlessness): | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| _______________________________________________________ | ||
| Supervision | ||
| • | Visiting: | _______________________________________________________ |
| • | Providing Emotional Support: | _______________________________________________________ |
| • | Providing Companionship: | _______________________________________________________ |
| • | Checking on the Patient: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| Organizing Home Care | ||
| • | Visiting Nurse: | _______________________________________________________ |
| • | Home Care: | _______________________________________________________ |
| • | Hospice Home Care: | _______________________________________________________ |
| • | Physical Therapy: | _______________________________________________________ |
| • | Ordering Equipment: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| Organizing Medical Care | ||
| • | Keeping Track of Appointments: | _______________________________________________________ |
| • | Picking Up Prescriptions: | _______________________________________________________ |
| • | Transportation to Appointments: | _______________________________________________________ |
| • | Acting as a Health Care Proxy: | _______________________________________________________ |
| • | Dealing with Emergency Hospital Visits: | _______________________________________________________ |
| • | Managing Deliveries of Supplies/Equipment: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| Managing Finances | ||
| • | Handling Insurance: | _______________________________________________________ |
| • | Maintaining Bank Account: | _______________________________________________________ |
| • | Collecting Social Security Benefits: | _______________________________________________________ |
| • | Paying Bills: | _______________________________________________________ |
| • | Paying for Items Not Covered by Insurance: | _______________________________________________________ |
| • | Will & Estate Planning: | _______________________________________________________ |
| • | Other: | _______________________________________________________ |
| _______________________________________________________ | ||
| Other | ||
|
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