|
Resident____________________________ |
Medical
Record#_____________ |
Room________ |
||||
|
|
|
|
||||
|
MOOD AND BEHAVIOR PATTERNS DURING THE THREE MONTH PERIOD ___/___/___ to ___/___/___ |
Behavior occurs 1-3 times per/week |
Behavior occurs 4-6 times per/week |
Behavior occurs 6-7 times per/week |
|
||
|
Be sure to rate
every item with an X |
|
|
|
|
||
|
1. Verbally expression of sadness,
hopelessness, or negative statements |
|
|
|
|
||
|
2. Asking same questions constantly |
|
|
|
|
||
|
3. Making same statements repetitively |
|
|
|
|
||
|
4. Easily angered, irritable, or easily
frustrated |
|
|
|
|
||
|
5. Making derogatory statements about self |
|
|
|
|
||
|
6. Expression of unrealistic fears |
|
|
|
|
||
|
7. Belief that
something terrible is about to happen |
|
|
|
|
||
|
8. Making numerous complaints about health |
|
|
|
|
||
|
9. Constantly seeking attention and
reassurance regarding care and nursing treatment |
|
|
|
|
||
|
10. Unable to get
to sleep |
|
|
|
|
||
|
12. Very restless
sleep or intermittent awakenings during night |
|
|
|
|
||
|
13. Unpleasant mood
in morning |
|
|
|
|
||
|
14. Sad or worried
facial expression |
|
|
|
|
||
|
15. Crying episodes |
|
|
|
|
||
|
16. Repetitive
movements such as pacing, wringing hands, restlessness, or picking |
|
|
|
|
||
|
17. Have lost
interest in others and withdrawn |
|
|
|
|
||
|
18. Expressed
thoughts of wanting to die |
|
|
|
|
||
|
19. Exhibiting
disruptive behavior |
|
|
|
|
||
|
20. Memory problem
or poor concentration |
|
|
|
|
||
|
21. Tired or have
loss of energy |
|
|
|
|
||
|
22. Sudden episodes
of nervousness or panic |
|
|
|
|
||
|
23. Fear of losing
control |
|
|
|
|
||
|
24. Very anxious in
social situations |
|
|
|
|
||
|
25. Expresses
belief someone is trying to harm him/her or is making life especially difficult |
|
|
|
|
||
|
26. Ritualistic or
obsessive behaviors |
|
|
|
|
||
|
27. Wandering
aimlessly |
|
|
|
|
||
|
28. Verbally
abusive behavior |
|
|
|
|
||
|
29. Physically
abusive to others |
|
|
|
|
||
|
30. Resists
personal care |
|
|
|
|
||
|
31. Sense (hear,
see, smell, touch, taste, or feel) things that others can’t |
|
|
|
|
||