Geriatric Mental Health Services

Geriatric Guide - Appendix 2: Worksheet for Measuring the Behavior

For Assessing Changes in Behavior in Residents of Long Term Care Facilities and.......
Getting Help When Needed

When does it occur? (Indicate as many as are applicable)– morning, afternoon, mealtime, bath time, bedtime, other__________________________

Who is present when the behavior occurs?

Visitor/s________________________________________________________________

Other residents__________________________________________________________

Staff __________________________________________________________________

How often does it happen (as many as are applicable)?
Once a day, once a week, twice a day, etc.?

What intervention have been tied?

______________________________________________________________________

With what results?

______________________________________________________________________

What seems to help?

______________________________________________________________________

What makes it worst?

______________________________________________________________________

___________________________________