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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
AM/PM
Visit end time
*
Hours
:
Minutes
AM
PM
AM/PM
Patient visit duration: (total minutes)
Mileage:
Type of contact:
*
In-Person
Telephone call
Virtual (Facetime, Skype, etc.)
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(more withdrawn; more sad; more angry; more depressed; etc.)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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