Volunteer Patient

Volunteer Services Activity Report

Patients Initials Patient I.D. Visit Date

Time In: (am; pm) Length of Visit

Total Travel Time Total Mileage

Type of Contact

Section A Type of Service needed Transportation	Description doctor appointment, church, haircut appointment
Shopping	grocery, library, errands, etc.
Respite	sit with patient for short periods of time while caregiver goes to church, shopping, appointments, etc.
Outings	fishing, special events, with patient or family member
Meals	cook meals in home, or bring meals to home
Companionship	read aloud, write letters, life review, play cards, play games or music, organize photo albums or papers, watch TV or movies, bird watch, take dictation, puzzles, crafts, etc.
Pampering	manicure, haircut, massage, pedicure, makeover, etc.
Gardening	take flowers, care for plants, help with gardening or yard work
Light Housekeeping	laundry, dishes, clean drawers, take out trash
Children	children on outings or to meetings
Phone Calls	make calls for patient and/or family
Emotional Support	grief
Organize	assist with organizing/paying bills, get stamps, assist in completing forms
Moving	assist with moving into new home
Phone Visits	check in calls
Other
Section B Describe Visit Activities

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Volunteer Name

Home
Contact Information If you should have any questions about our services, please contact one of our health care representatives.

Telephone
1-800-443-4788 or 770-925-4788
FAX 770-925-4619

Postal address
United Hospice
1626 Jeurgens Court
Norcross, GA 30093

Electronic mail
General
Information: information@united-hospice.com
Webmaster: webmaster@united-hospice.com