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(more withdrawn; more sad; more angry; more depressed; etc.)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

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