Daily Activity Log
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1DAILY ACTIVITY LOG
Client Name________________________________
Fax 847-480-5720 or email each week by noon Tuesday
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Date
Caregiver #1
Time In
Time Out
Caregiver #2
Time In
Time Out
Companionship
Med Reminder: TIME
Med Reminder: TIME
Med Reminder: TIME
Med Reminder: TIME
Med As Needed: TIME
WHAT
Med As Needed: TIME
WHAT
Bathing
Toileting Assistance
Personal Care
Shaving
Dressing/Undressing
Ambulating Assist
Transfer Assist
Reposition
Supervise Exercise
Breakfast
Lunch
Dinner
Snacks
Change Linens
Laundry
Clean Bathroom
Clean Kitchen
Vacuum, Mop Floors
Other
Transportation: Where
Errands w/o client
Calls to Office
Signature_____________________________________________________Date_______________
WRITE ADDITONAL NOTES ON REVERSE
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Parent category: Miscellaneous