Volunteer Patient/Family Visit ReportPlease enable JavaScript in your browser to complete this form.Patient's Name *Date of Contact *Volunteer Name *Volunteer Email *Arrival TimeDeparture TimeTravel TimeTotal Hours *FVHH Care CoordinatorErik MeeksJill ThorsenContact With:PatientSpouseSignificant OtherFamilyCaregiverHospice TeamFriendPlease check all that applyType of Contact:Personal VisitPhone ContactOtherPlease check all that applyPlace of Contact:HomeHospitalNursing HomeOtherPlease check all that applyMedicare Hospice Agency NameI provided the following services:Active listening/supportive presence for patientActive listening/supportive presence for familyRespite careFood preparationErrands/shoppingTransportationAssistance w/tasksInfo on relaxation and comfort measuresInfo on death/dying/grieving processInfo on community resourcesInfo on FVHH resourcesOtherObserved Changes:Patient coping issuesFamily coping issuesAppetite / nutritional statusSpiritual needsPain / DiscomfortPhysical ChangesLevel of AlertnessOtherPlease explain below in Comments fieldWas there a change in the patient's condition?YesNoIf yes, additional fields will show.Staff Team Member(s) Reported toDate Reported----------------------------------------------------------------------------------------------------------Volunteer Electronic Signature *Date SignedCommentsEmailSubmit