1986427 – Care Notes Library

Date

Caregiver Name

Patient Name

Caregiver Phone Number

Hygiene BathedBrushed TeethChanged ClothesApplied Foot CreamChanged Bedding/SheetsOther

Wellness
ExercisedStretchedMeditatedWent OutsideHobby 1: Flower ArrangementSpoke with Loved OneOther

Breakfast (Meal)

Time of Breakfast

Amount Eaten

Lunch (Meal)

Time of Lunch

Amount Eaten

Dinner(Meal)

Time of Dinner

Amount Eaten

Other (Meal)

Time of Other

Amount Eaten

Other (Meal)

Time of Other

Amount Eaten

Time Asleep

Time Awake

Quality of Sleep

Reason for Sleep Quality
Inconsistent SleepWoke up for FoodWoke up for Bathroom RegularlyAnxietyInsomnia (Unable to Fall Asleep)Physical Pain (body aches etc)Other

AM Pillbox
Levothyroxine 100mcg 1qam (if possible, before food on empty stomach. Dr. said its ok with am pills)-ThyroidMemantine 10mg 1bid - morning and evening-Dementia MedDonepezil 10mg 1qpm-Dementia MedValacyclovir 500mg 1bid - morning and evening- EPVLamotrigine 25 mg 1bid - morning and evening- anxiety, stress1 teaspoon Omega-3 1560mg Nordic Naturals with lunchVitamin D3 25mcg (1000 iu) liquid 1 drop with lunchFerrochel (Iron 27mg) 1/d (can be opened and added to food)Methyl B12 5000mcg sublingual 1/d (Jarrow)Gaba 750mg capsule with food ( new PRN, afternoons) calming, sundowningHumboldt Apothecary Deep Sleep with dinner 16.7 mg THC (1ml) calming

PM Pillbox
Boiron SleepCalm Homeopathic. 2 Tabs -SleepIntegrative Cortisol Manager 2 Tabs crushed at bedtime-add to apple sauce (can be given during crisis during the day) calmingMirtazapine 15mg -SleepMelatonin 5mg sublingual -sleep

Other
Only if he is displaying psychotic and/or highly aggressive behavior -Quetiapine 25mg

Daily Caregiver
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General

Hygiene and Wellness

Food Intake

Sleep

Medication Intake

Overall Wellbeing

Daily Caregiver Notes Library

Daily Caregiver Notes Form

General

Hygiene and Wellness

Food Intake

Sleep

Medication Intake

Overall Wellbeing

Daily Caregiver
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