Veteran Supplies & Safety Needs Checklist
Veteran Name:
Date
-
Month
-
Day
Year
Date
Caregiver Name:
Incontinence Supplies:
Adult diapers/briefs (e.g., Depends)
Bed pads/underpads
Wipes
Skin barrier cream
Personal Protective Equipment:
Gloves (non-latex or latex)
Mobility & Home Safety:
Grab bars for bathroom or hallways
Shower chair or bench
Non-slip bath mats
Walker or cane
Wheelchair
Lift assistance device
Ramp for entry/exit
Bed chunks
Other
Transportation & Emergency Services:
Needs transportation assistance (e.g., to appointments or errands)
Request assessment for transportation eligibility
Emergency alert bracelet or necklace (e.g., Life Alert)
Other
Medical & Comfort Items:
Blood pressure monitor
Oxygen supplies
Compression socks
Other
Caregiver Notes/Observations:
Signature:
Date Submitted:
-
Month
-
Day
Year
Date
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Should be Empty: