» Daily Record Form

Name of Support Worker*

First

Last

Date of Support Session

Session Start time*

:

Please use 24hr clock

Session End time*

:

Please use 24hr clock

1. Were there any issues regarding medication?*

a. Was Vincent wearing his emergency bracelet today?*

2. Give a brief account of what Vincent did today, including any physical exercise, mental exercise, outings, food preparation, cleaning etc*

3. Give a brief account of how Vincent was today, including mood, memory, word finding, motivation, confusion etc*

4. How much encouragement did Vincent need to do activities today (1-5, where 1 = not much and 5 = a lot)*

Comments

5. Did Vincent need help today with post/whiteboard?*

Comments

6. Was the flat clean and enough food available, and in date?*

7. If shopping, did Vincent need assistance with financial transactions?*

8. How much alcohol was in flat on arrival?*

9. How many empty cans were there?*

10. How much alcohol was bought?*

11. How much do you think he has drunk since last visit?*

12. Has Vincent had support from family since last visit?*

13. Did Vincent ask you to drop him to town at the end of your shift?’ Yes/no*

14. Did Vincent demonstrate good road safety awareness? Yes/no. If no please comment*

15. Any other comments/concerns*