{"id":3751,"date":"2026-01-28T20:13:38","date_gmt":"2026-01-28T20:13:38","guid":{"rendered":"https:\/\/fortresshealthcareservices.com\/?page_id=3751"},"modified":"2026-01-28T20:14:36","modified_gmt":"2026-01-28T20:14:36","slug":"care-note-form","status":"publish","type":"page","link":"https:\/\/fortresshealthcareservices.com\/index.php\/care-note-form\/","title":{"rendered":"Care Note Form"},"content":{"rendered":"\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3750-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3750\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/3751#wpcf7-f3750-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3750\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3750-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7dtx_version\" value=\"5.0.6\" \/>\n<\/fieldset>\n<div class=\"employment-application-form\">\n\t<h1>Weekly Care Note\n\t<\/h1>\n\t<h3>Shift Information\n\t<\/h3>\n\t<p><label>Caregiver Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"caregiver-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"caregiver-name\" \/><\/span> <\/label>\n\t<\/p>\n\t<p><label> Select Client *<br \/>\n<span class=\"wpcf7-form-control-wrap client_id\" data-name=\"client_id\"><select name=\"client_id\" class=\"wpcf7-form-control wpcf7-select wpcf7dtx wpcf7dtx-select\" aria-invalid=\"false\" required=\"required\" size=\"1\"><option value=\"\">System Error: Check API Connection<\/option><\/select><\/span><br \/>\n<\/label>\n\t<\/p>\n\t<p><label>Date of Visit<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"visit-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"visit-date\" \/><\/span> <\/label>\n\t<\/p>\n\t<div style=\"display: flex; gap: 20px;\">\n\t\t<p><label style=\"flex: 1;\">Shift Start Time<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"shift-start\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g. 9:00 AM\" value=\"\" type=\"text\" name=\"shift-start\" \/><\/span> <\/label>\n\t\t<\/p>\n\t\t<p><label style=\"flex: 1;\">Shift End Time<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"shift-end\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"e.g. 5:00 PM\" value=\"\" type=\"text\" name=\"shift-end\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<hr \/>\n\t<h3>Vitals & Assessment\n\t<\/h3>\n\t<div style=\"display: flex; gap: 20px;\">\n\t\t<p><label style=\"flex: 1;\">Blood Pressure<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vitals-bp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"e.g. 120\/80\" value=\"\" type=\"text\" name=\"vitals-bp\" \/><\/span> <\/label>\n\t\t<\/p>\n\t\t<p><label style=\"flex: 1;\">Pulse (Heart Rate)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vitals-pulse\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"e.g. 72\" value=\"\" type=\"number\" name=\"vitals-pulse\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div style=\"display: flex; gap: 20px;\">\n\t\t<p><label style=\"flex: 1;\">Temperature<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vitals-temp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"e.g. 98.6\" value=\"\" type=\"text\" name=\"vitals-temp\" \/><\/span> <\/label>\n\t\t<\/p>\n\t\t<p><label style=\"flex: 1;\">Respiration<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vitals-resp\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" placeholder=\"e.g. 16\" value=\"\" type=\"number\" name=\"vitals-resp\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label>Pain Level (0-10)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"vitals-pain\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"10\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"vitals-pain\" \/><\/span> <\/label>\n\t<\/p>\n<hr \/>\n\t<h3>Activities of Daily Living (ADLs)\n\t<\/h3>\n\t<p>Check all that apply during this visit.\n\t<\/p>\n\t<p><strong>Personal Care<\/strong>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"adl-personal\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"adl-personal[]\" value=\"Bathing \/ Showering\" \/><span class=\"wpcf7-list-item-label\">Bathing \/ Showering<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-personal[]\" value=\"Grooming \/ Shaving\" \/><span class=\"wpcf7-list-item-label\">Grooming \/ Shaving<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-personal[]\" value=\"Dressing Assistance\" \/><span class=\"wpcf7-list-item-label\">Dressing Assistance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-personal[]\" value=\"Toileting \/ Incontinence Care\" \/><span class=\"wpcf7-list-item-label\">Toileting \/ Incontinence Care<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"adl-personal[]\" value=\"Oral Hygiene\" \/><span class=\"wpcf7-list-item-label\">Oral Hygiene<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><strong>Nutrition & Mobility<\/strong>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"adl-nutrition\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"adl-nutrition[]\" value=\"Meal Preparation\" \/><span class=\"wpcf7-list-item-label\">Meal Preparation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-nutrition[]\" value=\"Feeding Assistance\" \/><span class=\"wpcf7-list-item-label\">Feeding Assistance<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-nutrition[]\" value=\"Medication Reminder\" \/><span class=\"wpcf7-list-item-label\">Medication Reminder<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-nutrition[]\" value=\"Walking \/ Transfer Assistance\" \/><span class=\"wpcf7-list-item-label\">Walking \/ Transfer Assistance<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"adl-nutrition[]\" value=\"Range of Motion Exercises\" \/><span class=\"wpcf7-list-item-label\">Range of Motion Exercises<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><strong>Household<\/strong>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"adl-household\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"adl-household[]\" value=\"Light Housekeeping\" \/><span class=\"wpcf7-list-item-label\">Light Housekeeping<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-household[]\" value=\"Laundry\" \/><span class=\"wpcf7-list-item-label\">Laundry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"adl-household[]\" value=\"Change Linens\" \/><span class=\"wpcf7-list-item-label\">Change Linens<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"adl-household[]\" value=\"Trash Removal\" \/><span class=\"wpcf7-list-item-label\">Trash Removal<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<hr \/>\n\t<h3>Narrative Note\n\t<\/h3>\n\t<p><label>Shift Summary \/ Client Status<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"narrative-note\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Describe the client&#039;s mood, any incidents, or changes in condition...\" name=\"narrative-note\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<hr \/>\n\t<h3>Signature\n\t<\/h3>\n\t<p>I certify that the above information is true and accurate.\n\t<\/p>\n\t<p><label>Sign Here (Use Finger or Mouse)<br \/>\n<div class=\"dscf7_signature\">\n\t\t\t<div class=\"dscf7_signature_inner\">\n\t\t\t\t<canvas id=\"digital_signature-pad_signature-field\" name=\"signature-field\" class=\"digital_signature-pad\" color=\"#000000\" backcolor=\"#dddddd\" width=\"300\" height=\"200\"><\/canvas>\n\t\t\t\t<input class=\"clearButton\" type=\"button\" value=\"+\">\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap signature-field\" data-name=\"signature-field\">\n\t\t\t\t<input class=\"wpcf7-form-control wpcf7-signature wpcf7-validates-as-signature dscf7-signature\" value=\"\" type=\"hidden\" name=\"signature-field\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-field-attachment\" class=\"wpcf7_input_signature-field_attachment\"\/>\n\t\t\t\t<input type=\"hidden\" name=\"signature-field-inline\" class=\"wpcf7_input_signature-field_inline\"\/>\n\t\t\t<\/span>\n\t\t<\/div><br \/>\n<\/label>\n\t<\/p>\n\t<div class=\"submit-row\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Care Note\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"Weekly Care Note Shift Information Caregiver Name Select Client * System Error: Check API Connection Date of Visit Shift Start Time Shift End Time Vitals & Assessment Blood Pressure Pulse (Heart Rate) Temperature Respiration Pain Level (0-10) Activities of Daily Living (ADLs) Check all that apply during this visit. Personal Care Bathing \/ ShoweringGrooming \/ ShavingDressing AssistanceToileting \/ Incontinence CareOral Hygiene Nutrition & Mobility Meal PreparationFeeding AssistanceMedication ReminderWalking \/ Transfer AssistanceRange of Motion Exercises Household Light HousekeepingLaundryChange LinensTrash Removal Narrative Note Shift Summary \/ Client Status Signature I certify that the above information is true and accurate. Sign Here (Use Finger or Mouse)","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/pages\/3751"}],"collection":[{"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/comments?post=3751"}],"version-history":[{"count":3,"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/pages\/3751\/revisions"}],"predecessor-version":[{"id":3754,"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/pages\/3751\/revisions\/3754"}],"wp:attachment":[{"href":"https:\/\/fortresshealthcareservices.com\/index.php\/wp-json\/wp\/v2\/media?parent=3751"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}