Caregiver Care Plan Caregiver Care Plan Select Patient(Required)-- Select Patient --Patient Full NameName of Staff First Middle Last Name of Patient/Client First Middle Last Client/Patient Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of birth MM slash DD slash YYYY AgeMarital statusmarried, single, divorced, separated, widowedGenderFemaleMaleOther Special considerationBody MechanicsTransfer Assist Stand Pivot Slide Board Sit up in chair Hoyer Ambulation Assist Cane Wheelchair Walker Crutches ROM/HEP Apply orthopedic device Other Personal Care | Assistance with ADLsBathing Tub Shower Bed Chair Shower Bench Perineal Care Hair Comb/Brush Shampoo Condition General Dress Shave Nail Skin care/grooming Oral Hygiene Clean dentures Brush teeth Mouthwash Oral Swabs Toileting Assist to commode/toilet Assist with bedpan/urinal Catheter care Homemaking Shop Straighten Clean bathroom & kitchen after use Clean kitchen after meal prep Make bed Change bed linen Personal laundry Medication reminder assistance Escort Appointment Companionship Vacuuming/Dusting Safety InstructionsOther/Record Temp A/O Intake/Output Pulse B/P Respiration Vitals Universal Precautions Mask Gown Gloves Wash Hands Physician Name First Last PhoneSpecial InstructionsPatient/Responsible Party Signature First Last Referred by:Date: MM slash DD slash YYYY