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:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other (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?

Mornings: __________________________________________________________________________
Afternoon __________________________________________________________________________
Evenings: __________________________________________________________________________
Nap time: __________________________________________________________________________
Bedtime: __________________________________________________________________________
Meals: ______________________________________________________________________________
Other _______________________________________________________________________________

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?
__________________________________________________________________________________________________________________________________________________________________________________________

Recreation
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 _____________________________________________________
Bathing __________________________________________________________
Shaving _________________________________________________________
Hair Care ________________________________________________________
Toileting _________________________________________________________
Personal Care ____________________________________________________
Dressing _________________________________________________________
Other/Additional Details___________________________________________

Cleanliness and Neatness
Indicate personal habits, areas of difficulty, special needs for protective clothing etc.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Bathroom
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?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Bathing
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?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PERSONAL PREFERENCES

Foods
List any favorite foods
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Eating Habits
Describe things like whether snacks are allowed, how often, types? Any precautions to be taken with monitoring them while eating, special utensils, etc.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Special Food Considerations
Describe foods to be avoided for swallowing considerations, gas, etc., whether meals should be prepared in a certain way (cut into small pieces, pureed, soft-foods, thickeners added, etc.)
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Drinks
Describe liquids to be avoided, whether thickeners need to be added, favorite drinks, etc. If there are special recipes or prepared drinks identify them.
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Sleeping Habits
What are their normal sleeping schedules? Should they be kept awake certain hours? What clothing do they prefer to sleep in? Do they prefer sleeping on their side or back? Is it okay for them to sleep on couch or other area?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Hobbies & Interests
Describe/let caretaker knows if there are items around the house reflecting the persons hobby/interest that could be brought out and talked about. Do they participate in a hobby on a regular basis, etc?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social Support 
Are there special people in their life who they may want to talk with or have visit? Who is allowed to visit in your absence? Who is not?

Name __________________________ Phone ______________ 
Address______________________________________________ 
City State Zip _______________________________________
Who they are: _______________________________________
They are: 
___ Allowed To Visit Anytime ___ Must Call First __ Must Wait Until You Return

Name __________________________ Phone ______________ 
Address______________________________________________ 
City State Zip _______________________________________
Who they are: _______________________________________
They are:
 ___ Allowed To Visit Anytime ___ Must Call First __ Must Wait Until You Return

Name __________________________ Phone ______________ 
Address______________________________________________ 
City State Zip _______________________________________
Who they are: _______________________________________
They are: 
___ Allowed To Visit Anytime ___ Must Call First __ Must Wait Until You Return

OTHER CONSIDERATIONS 
Identify all other things the caretaker should be aware of in your absence. Make sure they know where a copy of the EMERGENCY INFORMATION & DAILY MEDICATION SHEETS are that lists all critical contacts, phone numbers, etc. and provide specific medical information on your loved one. (Post them on the refrigerator)

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

APPOINTMENTS 
List all appointments that may be scheduled for your loved one during your absence that couldnt be changed. Do they go for therapy weekly? A day care facility? Is someone scheduled to come take them someplace? Are aids or nurses scheduled to visit?

Indicate whether the caretaker must provide transportation. If special transportation is required (i.e. non-emergency transport vehicle) make arrangements with that provider in advance, leave number for caretaker to verify pick up day before, etc.

Date	Time	Purpose	Contact/Phone	Directions	

					

					

					

DAILY HYGIENE SCHEDULE 
Sticking to a routine can be very important! 
Identify each activity that your loved one is accustomed to and any special thing the caretaker must consider. I.e. like using an electric toothbrush, frequency of brushing teeth, assistance with rinsing mouth/swallowing concerns, washing hair daily or every other day, 
once a week, etc.

Activity	Time(s)	Special Considerations	
Bath/Shower			
Mouth care (brushing, rinsing, etc. )			
Hair Care (washing, brushing)			
Shaving/frequency			
Fingernails (cutting, filing etc)			
Toenails (cutting, filing etc)			
Body skin care			
Face care			
Lip care (balms, moistures)			
Hand or feet skin care			
Eye care (drops, etc.)			
Normal massage(s)			
Rotation in bed			

			
			
Other			
Bedding changed			
Mattress protection			
Pillows desired			
Covering desired			
Incontinence products			

DAILY MEAL & SNACK SCHEDULE 

Identify normal meal and snack times. Indicate whether there are special dietary considerations for food and/or drinks. Any special cups, plates or utensils? What about wrists weights, clothing protectors or area where meal should be given?

Daily Calorie Intact Required: ________
Daily Clear Fluid Needs: ______________

Meal/Snack	Time	Special Considerations	

			

			

			

			

DAILY TV SCHEDULE (Tape on side of TV) 

Special Instructions:

Is it permissible for them to sleep with the TV on? Watch during meals? Is there any type of program that should be avoided (gory, horror movies, sexually explicit, etc.)
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________

List all regular favorite television programs and indicate level of importance i.e. whether they must see that particular show (i.e. caretaker is NOT to switch channels to watch another program). If there are favorite videos/movies you have that they enjoy watching add those.If you have cable service, most have smart boxes where you can pre-program favorite shows to come on automatically.

Morning Schedule

TIME	SHOW NAME	CHANNEL	IMPORTANCE	
06:00 				
06:30				
07:00				
07:30				
08:00				
08:30				
09:00				
09:30				
10:00				
10:30				
11:00				
11:30				
12:00 				
12:30				

Afternoon & Evening Schedule

TIME	SHOW NAME	CHANNEL	IMPORTANCE	
01:00				
01:30				
02:00				
02:30				
03:00				
03:30				
04:00				
04:30				
05:00				
05:30				
06:00				
06:30				
07:00				
07:30				
08:00				
08:30				
09:00				
09:30				
10:00				
10:30				
11:00				
11:30				
12:00				

INSTRUCTIONS FOR OPERATING 

Microwave:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Oven:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Television (include phone number and account for cable service, TV repairman etc.)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

VCR/DVD
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Washer/Dryer (preference for cold water, fabric softeners, etc.)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other:
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________