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

Appendix 2: Worksheet for Measuring the Behavior

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?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

___________________________________