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Interim Healthcare of Columbia
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Monthly Client Check In
Client Check In
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Email
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Name of Client
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Date of Check in
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How are you feeling today?
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1
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5
Not well
Have there been any changes in your daily routine or activities since our last check in?
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How well are you managing your meals and nutrition?
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Have you noticed any changed in your sleep pattern
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Do you have an adequate supply of medications and medical supplies?
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Are you keeping track of your appointments and medical visits?
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Do you have any concerns about falls or accidents?
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Are there any activities or hobbies you have been enjoying recently?
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How would you rate your overall satisfaction with our services so far?
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Poor
Exceptional
Are there any household tasks or errands you need assistance with?
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Do you have any suggestions for how we can better support you?
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Monthly Client Check In
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