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E: Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Provider Name: Date Time am/pm In Out Mon. Tub/Shower Assist to Dress Oral Hygiene Shampoo Hair Comb Hair Foot Care Nail Care Exercises Transfers Change Bedding Make Bed Laundry Mea Prep Kitchen Cleaning Bathroom Cleaning Vacuum/Dust Groceries/errand Transfers School transport DR Appointment Tues. Individual’s Signature Wed. Thurs. Fri. Sat. Provider Signature Sun. Response to Care Observations Monday: Tuesday: Wed.

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