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Daily Record Form - AJ CM360
Daily Record Form – AJ CM360
Name of Support Worker
*
First
Last
Date of Support Session
*
MM slash DD slash YYYY
Time shift started
*
:
Hours
Minutes
Please use 24hr clock
Time shift ended
*
:
Hours
Minutes
Please use 24hr clock
1. Please specify what activities AJ participated in today and give details of where you went.
*
Please detail ALL activities
2. Is AJ anxious or worried about anything? Yes or No?
*
Select Yes/No
Yes
No
If ‘yes’ please give detail (if you can) of what triggered the anxiety. For example, he often finds the issue of money a trigger for anxiety or visiting the hospital/doctors.
3. Does he complain of feeling breathless or unwell? Yes or No. If yes please encourage him to contact the doctor to make an appointment and give further detail in the box below
*
4. Did AJ have any cognitive difficulties i.e. problems with memory, word finding or concentrating?
*
Select Yes/No
Yes
No
If ‘yes’ please give an example of what he found difficult, did he lose his train of thought or could he not remember a particular word.
5. On a scale of 1-10 how is Ashley’s mood? (1 being low mood, 10 being excellent mood)
*
1
2
3
4
5
6
7
8
9
10
Please give further detail, for example, poor mood being caused by an argument or something that has annoyed him.
6. Was AJ mentally/physically fatigued today.
*
Select Yes/No
Yes
No
If 'yes' Please give details of when AJ was fatigued (time of day) and what may have caused the fatigue; for example, if known, did AJ take recreational drugs the night before or did he have back problems?
7. Did AJ complain about pain in his back/shoulder/hand today?
*
Select Yes/No
Yes
No
If ‘yes’ please detail. Please encourage him to make an appointment at the doctors or do this for him.
8. Please comment on the welfare of the dogs. Are there any cause for concern? Yes or No, if yes please give further details.
*
9. Did Ashley need any help to clear/tidy up? Please comment on the cleanliness of the house and detail any concerns that you may have.
*
10. Please give comments in relation to AJ’s wellbeing and whether you have any concerns (is there anything that you think the CM needs to know).
*
