HOME VISIT RECORD # ___

Name of Student: ________________________________________

Name of Client: __________________________________________
Date and Time of Visit: ____________________________________
Address: _______________________________________________

OBJECTIVES ACTIVITIES EVALUATION

________________________ ________________________
Student’s Signature Client’s Signature
 HEALTH TEACHING PLAN
Name of Student:__________________________________________
Date and Time of Visit: ________________________

I. Baseline Data
Name: ____________________
Sex: __________
Address: ________________________________________

II. Assessment of Client

III. Lesson Plan

BEHAVIORAL TEACHING
CONTENT OUTLINE EVALUATION
OBJECTIVES STRATEGIES
IV. Content Summary
ACTION REFLECTION ACTION SESSION

WEEK ___