Volunteer's Detailed Progress Report

Please submit this form no later than at the end of the month to:
HOSPICE MAUI
400 MAHALANI STREET
WAILUKU  HI  96793

Patient's name:  
Volunteer's name:  
Select one:  Home visit or Phone call        Date of visit or call:  
Starting time, including travel (use military):      Ending time, including travel (use military):  

Patient settings (check all that apply):
in bed   in a chair   bathroom   eating   self care   using a walker
Other:

Skin color (select one): pink   pale   yellow   dusky

Symptoms noted (check all that apply):
pain   nausea/vomiting   shortness of breath   cough   constipation   diarrhea   skin breakdown
other:

Mental/emotional state (check all that apply):
alert   oriented   responsive   angry   anxious   cheerful   complaining   confused   crying
frightened   lonely   reflective   sad   uncommunicative
other:

Patient expresses spiritual beliefs by (check all that apply):
verbalizes beliefs   prayer/meditation   reading materials   attends or asks to attend church
spiritual support persons visit in the home   asks for spiritual support   no expression during this visit
other:

Volunteer tasks (check all that apply):
patient   family   companionship   reading   respite   personal care   light housework   outing
errands   walking   range of motion   transportation
other:

The following space is for volunteer's comments:

Volunteer's E-mail: