Name:

Activity/ Task
% of Food
Eaten:
Breakfast
% of Food
Eaten: Lunch
Bathroom
Assistance
Incontinent/
Continent
Bladder
Incontinent/
Continent
Bowel
Transferring

Month:
1

1
0

1
1

1
2

1
3

1
4

1
5

1
6

1
7

1
8

1
9

2
0

2
1

2
2

2
3

2
4

2
5

2
6

2
7

2
8

2
9

3
0

Ambulation
Group
Exercise
Behaviors
Shower
Staff Initials

Use code below to chart on clients function for each Activity:

1-Indipendent
I- Incontinent
Food Consumption: 100%, 75%, 50%, 25%
1Independent with Exercise
2-Stand by Assistance
C- Continent
Behaviors: Y=Yes; N=No
2Participated with Assistance
3- Assist with 1 Person
Shower: Y=Yes; N=No
3- Refused
4- Total Care
4- Unable to Participate

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