Caregiving Checklist

Patient Name: Juan Dela Cruz Age: 40

Caregiver Name: Date:

Personal Care Activities and Exercise

 Shower  Walk Around
 Clean Teeth  Read Books
 Change Clothes  Watch TV
  Listen to the music
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 Meals
 Meal Time Amt
 Sandwich 8:00am 2 slices
Medical 
 Monitor Vitals 
 Medical Appointments 
 Organizing the medicine 
 Going to the Doctor 
 
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 Medicines
 Medicine Time Dosage
 Sleep Medicine 8:00pm 1 tb (mg)
Household 
 Laundry 
 Washing the Dishes 
 Trash 
 Vacuuming 
 Clean Bedroom 
 Clean Kitchen 
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