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Daily Record Form - EM - CM105
Daily Record Form – EM – CM105
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. What Goals/Activity was planned for today?
*
2. Did Ethan participate if so on a scale of 1-10 how engaged was he with the goal/activity? If not how did you motivate Ethan and what did you do instead?
*
3. Has Ethan taken Meds and had protein shake?
*
Yes
No
Did he require prompting?
4. Pain – is Ethan reporting pain? if so where/when i.e. before an activity/after an activity?
*
5. On a scale of 1-10 how severe is the pain? Pain relief taken?
*
6. Did Ethan shower and brush his teeth?
*
Yes
No
Did Ethan need prompting?
7. What has Ethan had to eat today?
*
Breakfast
Lunch
Dinner
8. How was Ethans Mood/behaviour/engagement with you today?
*
9. Was Ethan fatigued today?
*
Yes
No
If so, was there a reason?
10. Anything else the CM should be aware of?
*