You are on page 1of 1

Monthly Shower Assistance Log

Month: Patient:

Hair Caregiver Patient


Day Caregiver Type
Washed Initials Initials
1  Shower  Bath  Sponge Bath Y N
2  Shower  Bath  Sponge Bath Y N
3  Shower  Bath  Sponge Bath Y N
4  Shower  Bath  Sponge Bath Y N
5  Shower  Bath  Sponge Bath Y N
6  Shower  Bath  Sponge Bath Y N
7  Shower  Bath  Sponge Bath Y N
8  Shower  Bath  Sponge Bath Y N
9  Shower  Bath  Sponge Bath Y N
10  Shower  Bath  Sponge Bath Y N
11  Shower  Bath  Sponge Bath Y N
12  Shower  Bath  Sponge Bath Y N
13  Shower  Bath  Sponge Bath Y N
14  Shower  Bath  Sponge Bath Y N
15  Shower  Bath  Sponge Bath Y N
16  Shower  Bath  Sponge Bath Y N
17  Shower  Bath  Sponge Bath Y N
18  Shower  Bath  Sponge Bath Y N
19  Shower  Bath  Sponge Bath Y N
20  Shower  Bath  Sponge Bath Y N
21  Shower  Bath  Sponge Bath Y N
22  Shower  Bath  Sponge Bath Y N
23  Shower  Bath  Sponge Bath Y N
24  Shower  Bath  Sponge Bath Y N
25  Shower  Bath  Sponge Bath Y N
26  Shower  Bath  Sponge Bath Y N
27  Shower  Bath  Sponge Bath Y N
28  Shower  Bath  Sponge Bath Y N
29  Shower  Bath  Sponge Bath Y N
30  Shower  Bath  Sponge Bath Y N
31  Shower  Bath  Sponge Bath Y N

www.FreePrintableMedicalForms.com

You might also like