Note: (If Caregiver is on vacation, Alternate Caregiver provides care, checks "YES", fills, signs and submits form, and gets paid for this period!)
Positioning in Bed or Chair: Turning side to side, changing position while in bed or chair. Transferring: Moving in and out of bed; on/off chair, sofa, etc. (Exclude to/from bath/toilet) Locomotion/Ambulation (in home): Walking/wheeling in the home (if in wheelchair, self-sufficiency once in chair Locomotion/Ambulation (outside): Moving about outside the home (if in wheelchair, self-sufficiency once in chair Dressing upper body: Street clothes on/off from waist up. Includes prostheses and orthotics. Dressing lower body: Street clothes on/off from waist down. Includes prostheses and orthotics.
Eating: Taking in food by any method, including tube feeding. Bathing: Full body bath/shower or sponge bath (does not include washing of back & hair Personal Hygiene: Shampooing, combing hair, brushing teeth/dentures, shaving, applying makeup, washing & drying of face & hands, washing feet (EXCLUDES bath & showers) Toileting: using toilet, commode, bedpan/urinal, transferring on/off toilet, cleaning self after toilet use, incontinence care, changing pad, managing any special devices required (ostomy or catheter), and adjusting clothes.
Meal Preparation: Planning meals, cooking, assembling ingredients, setting out food and utensils. Ordinary Housework: Doing dishes, dusting, making bed, tidying up, laundry. Managing Finances: Paying bills, balancing checkbook, balancing household expenses. Managing Medications: Reminding to take medications, opening bottles. Phone Use: Making or receiving phone calls (with or without assistive devices, i.e. large numbers on phone, amplification devices
Shopping: Selecting food and household items, managing money. Transportation: Traveling to places that are beyond walking distances.
Wandering: Moving with no rational purpose seemingly oblivious to needs or safety. Verbally Abusive Behavior: Threatening, screaming or cursing at others.
Physically Abusive Behavior: Hitting, shoving or scratching. Socially Inappropriate Behavior: Disruptive sounds, noisiness, screaming, self-abusive acts, disrobing in public, smearing or throwing feces, rummaging, repetitive behavior or causing general disruption. Resists Care: Resists assistance with medications, ADL assistance, eating or changes in position. Does not include refusal of care.