Caregiver Daily Activity Log Form
Please complete this form to accurately log all daily care activities and observations for your client.
Caregiver Name
*
First Name
Last Name
Client Name
*
First Name
Last Name
Date of Care
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift End Time
*
Hour Minutes
AM
PM
AM/PM Option
Care Activities Performed
*
Personal hygiene (bathing, grooming, toileting)
Mobility assistance (walking, transfers)
Medication reminders/assistance
Light housekeeping
Companionship/social activities
Exercise/physical therapy
Other
Medications Administered
Client’s Mood/Condition Today
Stable
Improved
Declined
Other
Meals Served
Changes in Client’s Condition
Submit Log
Should be Empty: