Post Friendly Visit Form for Volunteers“A Friendly Visit, A Healthier You” Friendly Visit Checklist Client Name * First Name Last Name Date of Visit MM DD YYYY Volunteer Name First Name Last Name Physical Environment Safety hazards: Trip hazards: Clean: (Within reason) Yes No Client's Well-Being Hydration: Comfort: Hygiene: Overall Health: Emotional / Mental State: Mood: Behavior: Engagement: Meal and Nutrition Meal Quality: Client Satisfaction: Dietary Concerns: Food Safety: Additional Observations Changes: Unmet Needs: Interactions: Risks: Follow-up Actions: Notify Family / Caregiver Contact the client's designated family member or caregiver to inform him or her about the concern and potential hazards. Suggest they arrange for someone to help reorganize the home to promote safety: Yes No Assist with immediate needs Report the client's grocery needs to the organization or a designated team member. Arrange for a grocery delivery service or provide a list of local resources to assist a client (e.g., making lists with clients' input) Yes No Emotional Support Notify the organization about the client's feelings of loneliness Recommend scheduling an additional visit or a regular phone check-in to help alleviate their isolation Yes No Document Observations Record all findings in the client's file, including conversation details and actions taken. Ensure that this information is shared with the team to monitor the client's condition over time. Volunteer Signature: * I thank you for your dedication and help! -Chad Francour
