Volunteer Information

Volunteer Name:

Date of visit:

Patient Information

Patient ID:

Patient Name:

Location of Visit

On arrival patient was in:

Visit Information

On arrival patient appeared to be: (check all that apply)
Agitated
Alert
Asleep
Awake
Comfortable
Confused
Relaxed
Restless
Talkative
Short of Breath
Other

Services Provided: (check all that apply)
Bereavement
Cosmetology
Errands & Shopper
Friendly Visitor
Massage Therapist
Personal Historian/Patient Life Stories
Seamstress/Quilter
Respite (Caregiver Relief)
Singer/Instrumentalist
Visiting Dog
Veterans to Veterans
11th Hour Vigil
Personal Care
Other

At the end of the visit, the patient appeared to be: (check all that apply)
Agitated
Alert
Asleep
Awake
Comfortable
Confused
Relaxed
Restless
Talkative
Short of breath
Other

Did the patient complain of pain? If yes, please tell what actions you took: (check all that apply)
Yes
No

Patient took medication
Patient refussed medication
Notified the caregiver
Other
Volunteer notified
at LSH regarding

Travel Duration

Direct Duration

Patient of family concerns or comments:

Additional Comments:

Next Scheduled Contact:

Visit Non-Patient Hours

Please return this form within one week of the event.

Volunteer Event

In-Service Training

Community Event

Volunteer Lunch

Office Assistant

Bereavement

Sewing

Other

Comment or question regarding event comments: