Use the list below to identify and keep track of daily activities for long term care.

Help With Daily Activities

[_] Shopping

[_] Preparing meals

[_] Eating

[_] Laundry and other housework

[_] Home maintenance

[_] Paying bills and other money matters

[_] Bathing

[_] Dressing

[_] Grooming

[_] Going to the bathroom

[_] Remembering to take medicines

[_] Walking

[_] Other _______________________

[_] Other _______________________

Health Care Needs

(as recommended by a doctor or other health care provider)

[_] Physical therapy

[_] Speech therapy

[_] Occupational therapy

[_] Rehabilitation

[_] Medical nutritional therapy

[_] Oxygen

[_] Care for pressure ulcers or other wounds

[_] Alzheimer’s disease care

[_] Health monitoring (for diabetes, for example)

[_] Pain management

[_] Nursing care services

[_] Other medical services provided by a doctor or other clinician

[_] Other _______________________