Team Resources

Monthly Client Check-In Form

Please complete all required fields below. Submit one checklist for each client every month.

Your First & Last Name

Client First & Last Name

Date of Visit

Date of Visit (If Additional)

Where Did Visit(s) Occur?

Name Only, Address Not Needed

Total Time with Client + Travel (minutes, round to nearest)

Include time spent directly with the client, traveling, discussions with staff or others, phone calls, and any other client-related activities.

New medications or medication changes

Yes

No

Side effects noticed

Missed medications

Reported falls

Yes

No

Dietary changes

Yes

No

Client Weight

Ambulation / Mobility

Needs assistance

Uses device

Walks independently

Behavior changes or issues

Yes

No

Change in Mental Awareness or Cognition

Yes

No

Skin condition (cuts, bruises, rashes, breakdowns):

Yes

No

Client clean and well-groomed

Yes

No

Environment clean and safe

Yes

No

Somewhat

Recent Client Activities & Appointments

Contact with Family, Friends, or Other Individuals

Yes

No

N/A or Unknown

Positive Observations

A quick space for things going well for client.

Personal Items Needed

For Facility/Group Home Awareness Purposes Only

Details for “Yes” Responses: If you answered “Yes” above, describe the client’s concerns or needs.

Record any changes or notable observations in the client’s health, care needs, or overall well-being, even if no concerns were flagged earlier.

Do you feel you have the guidance, resources, and training you need to make accurate observations and report client needs during your visits?

Yes

No

If No, please describe what additional support or guidance would help:

Email

Monthly Client Check-In Form