General Caregiver Checklist

• Conducted on

  Date

• Caregiver on duty

• Patient/ward name/s

Patient's Morning Routine

• Has patient's medication been taken?

  Yes

  No

  N/A

• Has patient's personal grooming been taken care of?

  Yes

  No

  N/A

• Has patient had breakfast?

  Yes

  No

  N/A

• Are all food restrictions followed?

  Yes

  No

  N/A

• Has patient exercised?

  Yes

  No

  N/A

• Have all chores and housekeeping tasks (caregiver's or patient's) been taken care of?

  Yes

  No

  N/A

Patient's Afternoon Routine

• Has patient's medication been taken?

  Yes

  No

  N/A

• Has patient's personal grooming been taken care of?

  Yes

  No

  N/A

• Has patient had lunch?

  Yes

  No

  N/A

• Are all food restrictions followed?

  Yes

  No

  N/A

• Has patient exercised?

  Yes

  No

  N/A

• Have all chores and housekeeping tasks (caregiver's or patient's) been taken care of?

  Yes

  No

  N/A

Patient's Evening Routine

• Has patient's medication been taken?

  Yes

  No

  N/A

• Has patient's personal grooming been taken care of?

  Yes

  No

  N/A

• Has patient had dinner?

  Yes

  No

  N/A

• Are all food restrictions followed?

  Yes

  No

  N/A

• Has patient exercised?

  Yes

  No

  N/A

• Have all chores and housekeeping tasks (caregiver's or patient's) been taken care of?

  Yes

  No

  N/A

General Caregiver Tasks

• Have you done today's general housekeeping tasks?

  Yes

  No

  N/A

• Have you updated your patient's family of their wellbeing today?

  Yes

  No

  N/A

Others

• Additional comments about the day

• How is patient's overall health today?

  Good

  Fair

  Poor

  N/A

• Should patient consult with primary care provider immediately?

  Yes

  No

  N/A

• Caregiver name and signature

  Sign