» Daily Record Form

Name of Support Worker*

First

Last

Date of Support Session*

Time shift started*

:
HH

MM

Please use 24hr clock

Time shift ended*

:
HH

MM

Please use 24hr clock

1. Was LC appropriately dressed today?*

YES
NO

Please Comment.

2. Did Leah initiate any new activities other than planned appointments?*

YES
NO

3. Please specify what activities Leah participated in today and give detail of where you went.

4. Please provide a narrative in regards to the physical assistance required when outside the home today? i.e. opening/closing doors, carrying items, putting on/taking off coat, adjusting clothing after using the toilet.

5. Please indicate the level of physical assistance needed (on a scale of 1 -5) within the home.*

1 – required no support
2 – required little support
3 – required some support
4 – required medium level of support
5 – required high level of support

Please provide a narrative in regards to the physical assistance required when at home today? i.e. opening/closing doors, carrying items, putting on/taking off coat, adjusting clothing after using the toilet.

6. Please detail any cooking or food/drink preparation carried out today? For example, did she need prompting to; butter the bread, add the milk to the tea.

7. What physical support did Leah require when eating today? For example, cutting her food. Please give detail.

8. Please comment on Leah's mobility i.e. did she need any physical assistance, did she have any stumbles or falls, did she complain of any pain, discomfort or weakness? Did Leah lose balance? Please give as much information as possible.

8a. Did Leah suffer from any panic attacks? If yes, what happened before the attack? What happened during the attack? What helped in getting over the attack?*

YES
NO

Comments

8b. How did Leah sleep last night? What time did she go to bed and get up? Did she have a nap at any time during the day?

8c. Medication. Has LC taken her medication as directed today?*

YES
NO

8d. Any changes? Any differences in effect? (either noticed by you or that Leah or Aaron have noticed).

9. What support did Leah require when managing her money? For example, taking money out of her purse, working out how much money to give and checking her change.

10. Did Leah ask for any assistance to go through bills/letters/correspondence? If so, please detail what she needed help with and detail any cognitive difficulties.*

YES
NO

Please comment if necessary

11. Please provide a narrative detailing the neuropsychological observations you have made and the neuropsychological support that Leah has needed today. Please see questions below and refer to the 'Glossary of Terms'. a) Leah's mood – how was her mood today? b) Anxiousness – was she worried or anxious about anything today? c) Emotion – was she emotional about anything and please give detail. d) Did Leah's children feature in part of any discussion or activity today? e) Please detail any positive interactions between Aaron and Leah today. f) Please detail any support provided by Aaron. g) Did Leah have any problems with her memory, word finding or expressing herself. Please detail. h) Please detail any difficulties with concentration. i) Did Leah need neuro psychological support when dealing with the general public? j) Was Leah mentally fatigued today? Please give detail. k) Was Leah physically tired today? Please detail. l) Please give comments in relation to Leah's well-being.

Please provide details of conversations regarding the children; LC’s thoughts, feelings and actions.

Daily Record Form – Leah C