Daily Record Form - EM - CM105 - Stokes Case Management

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?*

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