(615) 717-0077
(615) 424-4376
(615) 891-7685
devotedhcinc@gmail.com
1653 Bridgecrest Dr, Antioch, TN 37013
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Home
About
Services
Companionship
Home Health Aide
Personal Care Assistant
Homemaker
Companion/Sitter
Live-In Caregiver
Blog
Service Areas
Careers
Forms
Client Forms
Staff Forms
Resources
Contact
Client Name
Client Record #
DAY
SUN
MON
TUE
WED
THURS
FRI
SAT
Date
Date (SUN):
Date (MON):
Date (TUE):
Date (WED):
Date (THURS):
Date (FRI):
Date (SAT):
Time In
Time In (SUN):
Time In (MON):
Time In (TUE):
Time In (WED):
Time In (THURS):
Time In (FRI):
Time In (SAT):
Time Out
Time Out (SUN):
Time Out (MON):
Time Out (TUE):
Time Out (WED):
Time Out (THURS):
Time Out (FRI):
Time Out (SAT):
Client Initials
Client Initials (SUN):
Client Initials (MON):
Client Initials (TUE):
Client Initials (WED):
Client Initials (THURS):
Client Initials (FRI):
Client Initials (SAT):
Assigned Task
Every Visit
Client Request
SUN
MON
TUE
WED
THURS
FRI
SAT
Client initials
Vacuum sweep floor
Vacuum sweep floor / Every Visit:
x
Vacuum sweep floor / Client Request:
x
Vacuum sweep floor (SUN):
x
Vacuum sweep floor (MON):
x
Vacuum sweep floor (TUE):
x
Vacuum sweep floor (WED):
x
Vacuum sweep floor (THURS):
x
Vacuum sweep floor (FRI):
x
Vacuum sweep floor (SAT):
x
Vacuum sweep floor (Client Initials):
Dust furniture
Dust furniture / Every Visit:
x
Dust furniture / Client Request:
x
Dust furniture (SUN):
x
Dust furniture (MON):
x
Dust furniture (TUE):
x
Dust furniture (WED):
x
Dust furniture (THURS):
x
Dust furniture (FRI):
x
Dust furniture (SAT):
x
Dust furniture (Client Initials):
Polish furniture
Polish furniture / Every Visit:
x
Polish furniture / Client Request:
x
Polish furniture (SUN):
x
Polish furniture (MON):
x
Polish furniture (TUE):
x
Polish furniture (WED):
x
Polish furniture (THURS):
x
Polish furniture (FRI):
x
Polish furniture (SAT):
x
Polish furniture (Client Initials):
Clean mirrors
Clean mirrors / Every Visit:
x
Clean mirrors / Client Request:
x
Clean mirrors (SUN):
x
Clean mirrors (MON):
x
Clean mirrors (TUE):
x
Clean mirrors (WED):
x
Clean mirrors (THURS):
x
Clean mirrors (FRI):
x
Clean mirrors (SAT):
x
Clean mirrors (Client Initials):
Wet mop floors
Wet mop floors / Every Visit:
x
Wet mop floors / Client Request:
x
Wet mop floors (SUN):
x
Wet mop floors (MON):
x
Wet mop floors (TUE):
x
Wet mop floors (WED):
x
Wet mop floors (THURS):
x
Wet mop floors (FRI):
x
Wet mop floors (SAT):
x
Wet mop floors (Client Initials):
Clean kitchen
Clean kitchen / Every Visit:
x
Clean kitchen / Client Request:
x
Clean kitchen (SUN):
x
Clean kitchen (MON):
x
Clean kitchen (TUE):
x
Clean kitchen (WED):
x
Clean kitchen (THURS):
x
Clean kitchen (FRI):
x
Clean kitchen (SAT):
x
Clean kitchen (Client Initials):
Clean inside windows
Clean inside windows / Every Visit:
x
Clean inside windows / Client Request:
x
Clean inside windows (SUN):
x
Clean inside windows (MON):
x
Clean inside windows (TUE):
x
Clean inside windows (WED):
x
Clean inside windows (THURS):
x
Clean inside windows (FRI):
x
Clean inside windows (SAT):
x
Clean inside windows (Client Initials):
Change bed linen
Change bed linen / Every Visit:
x
Change bed linen / Client Request:
x
Change bed linen (SUN):
x
Change bed linen (MON):
x
Change bed linen (TUE):
x
Change bed linen (WED):
x
Change bed linen (THURS):
x
Change bed linen (FRI):
x
Change bed linen (SAT):
x
Change bed linen (Client Initials):
Prepare lunch
Prepare lunch / Every Visit:
x
Prepare lunch / Client Request:
x
Prepare lunch (SUN):
x
Prepare lunch (MON):
x
Prepare lunch (TUE):
x
Prepare lunch (WED):
x
Prepare lunch (THURS):
x
Prepare lunch (FRI):
x
Prepare lunch (SAT):
x
Prepare lunch (Client Initials):
Prepare food for next day
Prepare food for next day / Every Visit:
x
Prepare food for next day / Client Request:
x
Prepare food for next day (SUN):
x
Prepare food for next day (MON):
x
Prepare food for next day (TUE):
x
Prepare food for next day (WED):
x
Prepare food for next day (THURS):
x
Prepare food for next day (FRI):
x
Prepare food for next day (SAT):
x
Prepare food for next day (Client Initials):
Laundry hand wash
Laundry hand wash / Every Visit:
x
Laundry hand wash / Client Request:
x
Laundry hand wash (SUN):
x
Laundry hand wash (MON):
x
Laundry hand wash (TUE):
x
Laundry hand wash (WED):
x
Laundry hand wash (THURS):
x
Laundry hand wash (FRI):
x
Laundry hand wash (SAT):
x
Laundry hand wash (Client Initials):
Hang out clothes
Hang out clothes / Every Visit:
x
Hang out clothes / Client Request:
x
Hang out clothes (SUN):
x
Hang out clothes (MON):
x
Hang out clothes (TUE):
x
Hang out clothes (WED):
x
Hang out clothes (THURS):
x
Hang out clothes (FRI):
x
Hang out clothes (SAT):
x
Hang out clothes (Client Initials):
Clean refrigerator
Clean refrigerator / Every Visit:
x
Clean refrigerator / Client Request:
x
Clean refrigerator (SUN):
x
Clean refrigerator (MON):
x
Clean refrigerator (TUE):
x
Clean refrigerator (WED):
x
Clean refrigerator (THURS):
x
Clean refrigerator (FRI):
x
Clean refrigerator (SAT):
x
Clean refrigerator (Client Initials):
Defrost refrigerator
Defrost refrigerator / Every Visit:
x
Defrost refrigerator / Client Request:
x
Defrost refrigerator (SUN):
x
Defrost refrigerator (MON):
x
Defrost refrigerator (TUE):
x
Defrost refrigerator (WED):
x
Defrost refrigerator (THURS):
x
Defrost refrigerator (FRI):
x
Defrost refrigerator (SAT):
x
Defrost refrigerator (Client Initials):
Clean oven
Clean oven / Every Visit:
x
Clean oven / Client Request:
x
Clean oven (SUN):
x
Clean oven (MON):
x
Clean oven (TUE):
x
Clean oven (WED):
x
Clean oven (THURS):
x
Clean oven (FRI):
x
Clean oven (SAT):
x
Clean oven (Client Initials):
Clean bathroom sink
Clean bathroom sink / Every Visit:
x
Clean bathroom sink / Client Request:
x
Clean bathroom sink (SUN):
x
Clean bathroom sink (MON):
x
Clean bathroom sink (TUE):
x
Clean bathroom sink (WED):
x
Clean bathroom sink (THURS):
x
Clean bathroom sink (FRI):
x
Clean bathroom sink (SAT):
x
Clean bathroom sink (Client Initials):
Clean tub/shower
Clean tub/shower / Every Visit:
x
Clean tub/shower / Client Request:
x
Clean tub/shower (SUN):
x
Clean tub/shower (MON):
x
Clean tub/shower (TUE):
x
Clean tub/shower (WED):
x
Clean tub/shower (THURS):
x
Clean tub/shower (FRI):
x
Clean tub/shower (SAT):
x
Clean tub/shower (Client Initials):
Clean toilet
Clean toilet / Every Visit:
x
Clean toilet / Client Request:
x
Clean toilet (SUN):
x
Clean toilet (MON):
x
Clean toilet (TUE):
x
Clean toilet (WED):
x
Clean toilet (THURS):
x
Clean toilet (FRI):
x
Clean toilet (SAT):
x
Clean toilet (Client Initials):
Make bed
Make bed / Every Visit:
x
Make bed / Client Request:
x
Make bed (SUN):
x
Make bed (MON):
x
Make bed (TUE):
x
Make bed (WED):
x
Make bed (THURS):
x
Make bed (FRI):
x
Make bed (SAT):
x
Make bed (Client Initials):
Prepare breakfast
Prepare breakfast / Every Visit:
x
Prepare breakfast / Client Request:
x
Prepare breakfast (SUN):
x
Prepare breakfast (MON):
x
Prepare breakfast (TUE):
x
Prepare breakfast (WED):
x
Prepare breakfast (THURS):
x
Prepare breakfast (FRI):
x
Prepare breakfast (SAT):
x
Prepare breakfast (Client Initials):
Prepare dinner
Prepare dinner / Every Visit:
x
Prepare dinner / Client Request:
x
Prepare dinner (SUN):
x
Prepare dinner (MON):
x
Prepare dinner (TUE):
x
Prepare dinner (WED):
x
Prepare dinner (THURS):
x
Prepare dinner (FRI):
x
Prepare dinner (SAT):
x
Prepare dinner (Client Initials):
Laundry
Laundry / Every Visit:
x
Laundry / Client Request:
x
Laundry (SUN):
x
Laundry (MON):
x
Laundry (TUE):
x
Laundry (WED):
x
Laundry (THURS):
x
Laundry (FRI):
x
Laundry (SAT):
x
Laundry (Client Initials):
Transport/escort
Transport/escort / Every Visit:
x
Transport/escort / Client Request:
x
Transport/escort (SUN):
x
Transport/escort (MON):
x
Transport/escort (TUE):
x
Transport/escort (WED):
x
Transport/escort (THURS):
x
Transport/escort (FRI):
x
Transport/escort (SAT):
x
Transport/escort (Client Initials):
Take for a walk
Take for a walk / Every Visit:
x
Take for a walk / Client Request:
x
Take for a walk (SUN):
x
Take for a walk (MON):
x
Take for a walk (TUE):
x
Take for a walk (WED):
x
Take for a walk (THURS):
x
Take for a walk (FRI):
x
Take for a walk (SAT):
x
Take for a walk (Client Initials):
Shopping
Shopping / Every Visit:
x
Shopping / Client Request:
x
Shopping (SUN):
x
Shopping (MON):
x
Shopping (TUE):
x
Shopping (WED):
x
Shopping (THURS):
x
Shopping (FRI):
x
Shopping (SAT):
x
Shopping (Client Initials):
Socialization
Socialization / Every Visit:
x
Socialization / Client Request:
x
Socialization (SUN):
x
Socialization (MON):
x
Socialization (TUE):
x
Socialization (WED):
x
Socialization (THURS):
x
Socialization (FRI):
x
Socialization (SAT):
x
Socialization (Client Initials):
Assist with correspondence
Assist with correspondence / Every Visit:
x
Assist with correspondence / Client Request:
x
Assist with correspondence (SUN):
x
Assist with correspondence (MON):
x
Assist with correspondence (TUE):
x
Assist with correspondence (WED):
x
Assist with correspondence (THURS):
x
Assist with correspondence (FRI):
x
Assist with correspondence (SAT):
x
Assist with correspondence (Client Initials):
Bill paying
Bill paying / Every Visit:
x
Bill paying / Client Request:
x
Bill paying (SUN):
x
Bill paying (MON):
x
Bill paying (TUE):
x
Bill paying (WED):
x
Bill paying (THURS):
x
Bill paying (FRI):
x
Bill paying (SAT):
x
Bill paying (Client Initials):
Friendly visit check
Friendly visit check / Every Visit:
x
Friendly visit check / Client Request:
x
Friendly visit check (SUN):
x
Friendly visit check (MON):
x
Friendly visit check (TUE):
x
Friendly visit check (WED):
x
Friendly visit check (THURS):
x
Friendly visit check (FRI):
x
Friendly visit check (SAT):
x
Friendly visit check (Client Initials):
Phone check/monitor
Phone check/monitor / Every Visit:
x
Phone check/monitor / Client Request:
x
Phone check/monitor (SUN):
x
Phone check/monitor (MON):
x
Phone check/monitor (TUE):
x
Phone check/monitor (WED):
x
Phone check/monitor (THURS):
x
Phone check/monitor (FRI):
x
Phone check/monitor (SAT):
x
Phone check/monitor (Client Initials):
Client or responsible party signature:
Clear
Date:
Agency Employee Signature/Title:
Clear
Date:
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