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Visit Note

"Quality Care. Lower Costs. Stronger Communities."

Clare’s is dedicated to preserving healthcare equity across Massachusetts. We fight rising insurance costs for the working class by providing critical support to community healthcare workers. By lifting the burden off case managers and nurses, we ensure our members receive the extra care and attention they deserve—no matter their income.

Your Full Name

Today's Date

Your Role

Your Role

Visit Type

Senior Name

❤️

Senior is seen happy, healthy and cared for. If answer is No please comment

Senior is seen happy, healthy and cared for. If answer is No please comment
A
B

If no please explain

❤️

Did senior get flu vaccination for this year (2026)?

Did senior get flu vaccination for this year (2026)?
A
B

Senior Smoke?

Senior Smoke?
A
B

If Yes- how many do you smoke per day?

Senior Alcohol use ?

Senior Alcohol use ?
A
B

If Yes- how much does senior drink per day?

Senior is a Diabetic?

Senior is a Diabetic?
A
B

If Yes- how many times per day & what is the reading today?

If Yes how often check blood sugar?

Senior has Hypertension?

Senior has Hypertension?
A
B

If yes - Does Senior check Blood Pressure at home?

If yes - Recent BP Number?

Senior has Asthma ?

Senior has Asthma ?
A
B

If yes - does senior has a rescue inhaler & can show you how to use it?

All yes answers please provide Comments

Recent History (Last 3 Months)Any Falls? (Yes + Comments)

Recent History (Last 3 Months)Any Falls? (Yes + Comments)
A
B

All yes answers please provide Comments

Recent History (Last 3 Months) Any Hospitalizations? (Yes + Comments)

Recent History (Last 3 Months) Any Hospitalizations? (Yes + Comments)
A
B

All yes answers please provide Comments


Recent History (Last 3 Months) Any ER use? (Yes + Comments)

Recent History (Last 3 Months) Any ER use? (Yes + Comments)
A
B
❤️

comments

If senior home has any recent medical records please upload here