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Volunteer Progress Form

Volunteer Progress Notes

"*" indicates required fields

Volunteer Name*

First Last

Email*

Phone

Patient First Name & LAST INITIAL ONLY*

Patient Visit

Visit Made

Visit Missed

Missed Visit Date*

MM slash DD slash YYYY

Explanation of Missed Visit*

Date of Visit*

MM slash DD slash YYYY

Visit start time*

Hours

:

Minutes

AM/PM

Visit end time*

Hours

:

Minutes

AM/PM

Patient visit duration: (total minutes)

Mileage:

Type of contact:*

Volunteer's observations of patient's physical condition:

Sleeping

Comfortable

Uncomfortable

Weak

Low energy

Increased energy

Well groomed

Agitated

Unresponsive

Other

Note for other:

Did the patient appear to have any pain?

Yes

No

(hesitant to move; frowning; clenched jaw; tense; restless; squirming; moans; grunts; complains of pain)

Was the patient short of breath?

Yes

No

Volunteer's observations of patient's emotions and attitude:

Content

Calm

Happy

Lonely

Realistic

Cheerful

Sad

Anxious

Upset

Positive

Negative

N/A

Other:

Note for other emotions/attitude:

Volunteer's observations of patient's behavior:

Joking

Laughing

Crying

Quiet

Talkative

N/A

Other

Note for other behavior:

Did the patient/family member show any significant emotional or behavioral changes since your last visit?

Yes

No

(more withdrawn; more sad; more angry; more depressed; etc.)

If yes, please describe change:

Does the patient/family member identify a need they don't know how will be met?

Yes

No

(transportation; housekeeping help; etc.)

If yes, please list concern:

Volunteer's observations of the care provider/family member

Well rested

Good spirits

Managing

Tired

Struggling emotionally

Other:

Note for other observations:

What did the volunteer do for the patient/family member?

Visited

Read to patient

Comforting presence

Respite for care provider

Memory making

Took for walk

Watched TV together

Played game/cards

Helped with tasks

Shared hobby

Played music

Cooked/Delivered meal

Errands/shopping

Other

Note for other activity performed:

Other pertinent information not already addressed:

Next visit scheduled?

Yes

No

Date of next scheduled visit

MM slash DD slash YYYY

If no, why not?

Δ

Upcoming Events

Oct

10

Rock River Center Wellness Fair

Oct

13

Comfort In Community (Grief Group)

Nov

02

Annual Memorial Service

Dec

02

Giving Tuesday

Dec

06

Angel Ball

See all Upcoming Events >>

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