Care To Stay Home

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Client name

Visit date

AE initials

Client age

Height / weight

Office / market

Primary condition / diagnosis (optional)

Who else is in the home?

Supportive devices

Caregiver limitations to note

Your field notes

Helpful things to cover

• Client mood and demeanor • Daily tasks that seem most challenging • Home environment and layout • Personality, preferences, and routine • Family dynamics and input • What a great day looks like for them

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