HD Helpful Forms
Caregiver Daily Instructions-Page 1


Index Page
Caregiver Daily Instructions-Page 1
The lead in information under each sub-section is only to provide you an idea of what you can write to describe your loved ones special needs.  If you highlight the information on this page, then copy it onto a Word document, you can modify it and personalize
the information, then save as your own document.
Special Care Instructions For


Personality Traits


General description

Describe what living with he/she is like, any unusual habits or traits requiring

special attention.


Basic Characteristics & Personality

Provide overall description of personality and describe any unique characteristics, which would help the caretaker understand any special needs


Abilities & Skills

Describe what they can do alone, things they may need assistance with etc..  Things such as walking, using bathroom, eating, handling controls for TV, using phone, etc.


Able To Do Without Assistance:

Needs some assistance:

Needs full assistance:


(describe things they may get upset if you try to do for them):


Physical Abilities


Communication Skills

Describe any problems with communication, special signals used, storyboards or any devices used to help them communicate.


Physical Mobility

Describe in detail any special requirements where assistance may be needed like getting up from a sitting/laying position, wheelchair, toilet, walking, etc. and how the person feels most comfortable getting assistance (i.e. hold from behind; lift from front until stable on feet, etc.)


Hearing Ability

Do they wear a hearing aid?  Does volume of TV/radio need to be at a special level? Is there any sensitivity to loud noises?  What, if anything, should be avoided?


Seeing Ability

Do they wear glasses, if so what are they needed for? (Reading, TV, walking, etc.)


Special Considerations:

Do they have a movement disorder where special consideration is needed? Are things such as special utensils or wrist weights, etc. utilized?


Special Places


Favorite Setting

Is there a favorite spot in the house they would prefer being in during different times of the day?  A special chair?  Are there areas that should be avoided?  Why?





Nap time:





Favorite Places/Places they like to go

Do they like to take a walk daily?  Have coffee with a neighbor? Go to the movies?  Indicate where the caretaker may take them in your absence.


Entertainment Preferred

Describe what they enjoy doing the most in their daily routine.  Do they like having a book or newspaper read to them?  Listen to a favorite tape, radio or TV station?  Are there games they enjoy playing alone or with someone?



Are there daily or weekly schedules of outings?  Do they enjoy being taken to a nearby park? Will someone be taking them to a movie, etc..


Habits & Hygiene


Personal Habits

Describe any personal traits the caretaker should be aware of: for example if the person hates bathing, changing clothes, changes clothes frequently, or has any compulsive tendencies.


Grooming (see Daily Schedules below)

Indicate how much assistance is required and normal daily schedule for each.


Dental Care



Hair Care


Personal Care


Other/Additional Details


Cleanliness and Neatness

Indicate personal habits, areas of difficulty, special needs for protective clothing etc.



Describe any special needs that should be considered.  What is their level of urgency, i.e. should they be taken immediately to a restroom when they indicate they need to relieve themselves?  Are they incontinent?  If yes, what special things need to be considered?



Do they need assistance?  Prefer shower or tub?  Any special equipment, like a tub chair required?  Do they have any preference for soaps or shampoos?  Do they like to linger or get it over with quickly?  What is their level of modesty, what might embarrass them?


Caregiver Daily Instructions-Page 2