Activity Levels Activity Levels Select Patient(Required)-- Select Patient --Adams, Kristal (DOB: 08/05/1952)Bond, Latrice (DOB: 12/29/1968)Brown, Marqett (DOB: 12/03/1993)De Ceballos, Rosarios (DOB: 01/02/1949)Dulianto, Teobaldo (DOB: 11/27/1930)Dwana, Jones (DOB: 03/16/1975)eric, eric eric (DOB: 12/31/1970)Freeman, Lenora (DOB: 10/07/1930)Garvy, Sharon (DOB: 07/29/1961)Gilbert, Rosa (DOB: 03/12/1928)Jordan, Larry (DOB: 02/07/0052)Kaifakhadi, Abdulraheem (DOB: 11/15/1950)Kawaly, Wilhemina (DOB: 12/23/1934)Mack, Roberta (DOB: 03/07/1938)Mendez, Ana (DOB: 11/21/1948)Morton, Joseph (DOB: 02/24/1941)Norris, Navi (DOB: 07/11/2000)Patrick, Ladonna (DOB: 12/14/1980)Rodriguez, Jeremiah (DOB: 12/19/2007)Turner, Linda Hall (DOB: 08/22/1938)Willie, Dolores (DOB: 05/17/1946)Wilson, Mary (DOB: 05/15/1962)Wright, Trevon (DOB: 07/29/2004)Patient Full NameMobility and Transfers: Dependent Independent Need assistance Standby One person transfer assist Two-person transfer assist Devices/Equipment needed to aid in ambulatingDevices/Equipment needed to aid in transferBathing: Dependent Independent Assist Cue Uses transfer bench or shower chair Personal Hygiene: hair, nails, skin, oral care Dependent Independent Assist Cue Uses transfer bench or shower chair Toileting: bladder, bowel routine, ability to access toilet Dependent Independent Assist Cue Incotinent bowel Incontinent bladder Dressing Dependent Independent Assist Cue Health maintenance needs Reinforce diet education Supervision of blood sugar monitoring Routinecare ofprosthetic/orthotic device education on medical equipment use or maintenance Referral to physician Other health education needed Other Eating and Drinking: Dependent Independent Assist Cue Health Maintenance Needs NotesGeneral physical condition Improving Unstable Deteriorating Other Please enter details if you selected otherNurse Monitor visit: Initial Monthly 45 Day 3 - Month Activities of Visit: Developed Caregiver Support Plan Provided Information and Training to Caregiver Reviewed Caregiver Support Pian Assessed/Monitored Caregiver Assessed/Monitored :articipant Caregiver Name First Last Patient Name First Last Patient/Representative SignatureName of RN First Last Date MM slash DD slash YYYY