Behavior Profile
Orientation
1. Fails to recognize friends
2. Fails to recognize family
3. Forgets year
4. Forgets month
5...
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Caregiver worksheet for those helping individuals with Alzheimer's

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This worksheet was referenced in my SXSW talk: Helping Aunt Ginny; Alzheimer's, Technology and Me. To see the Google Doc template, go here: https://drive.google.com/previewtemplate?id=0Ao3I_RGlqjEgdFhfZHc5YWxsOTFxSlR0V0pVTkRxSUE&mode=public

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Caregiver worksheet for those helping individuals with Alzheimer's

  1. 1. Behavior Profile Orientation 1. Fails to recognize friends 2. Fails to recognize family 3. Forgets year 4. Forgets month 5. Forgets day of the week 6. Unable to name place (town, etc) 7. Fails to recognize familiar places 8. Gets lost in neighborhood (walking) 9. Gets lost driving 10. Gets lost in own home 11. More confused at night 12. More confused in new places 13. Wanders and gets lost Memory 14. Loses/misplaces small items 15. Loses/misplaces valuable things 16. Forgets to pay bills 17. Forgets to eat 18. Unable to recall what was read 19. Forgets to turn things off 20. Forgets what the conversation is about 21. Unable to follow what is on TV 22. Forgets to bathe 23. Forgets major events of the day 24. Forgets major events of the week 25. Forgets major events of the distant past Language 26. Unable to initiate conversation 27. Misunderstands what others say 28. Unable to respond to questions 29. Has trouble finding the right words 30. Just speaks in phrases 31. Avoids questions 32. Unable to verbalize needs 33. Repeatedly says same things 34. What is said makes little sense Ambulation/Movement 35. Walks short, shuffling gait 36. Gait slow and labored 37. Tires easily when walking 38. Unable to get up from chair alone 39. Unable to use stairs 40. Unable to use eating utensils 41. Unable to write name 42. Hands/arms shake Behavior problems 43. Has problems sleeping 44. Has toileting accidents 45. Talks excessively about past 46. Denies problems 47. Gets upset easily 48. Becomes physically violent 49. Shows poor judgement 50. Has trouble taking medications 51. Drives unsafely 52. Very withdrawn, refuses to leave house 53. Very nervous and restless 54. Walks and paces constantly 55. Very suspicious/paranoid 56. Has delusional ideas 57. Has hallucinations 58. Sexually inappropriate Other? This handy chart was in Alzheimer's: A Caregiver's Guide and Sourcebook. I was using this to determine when things reached a critical point. How often it occurs How bothersome Always Usually Sometimes Never Extremely Very much Moderately A little Not at all A little Sometimes Never How much it bothers you Extremely Very much Moderately A little Not at all How often it occurs Always Usually Sometimes Never How much it bothers you Extremely Very much Moderately A little Not at all How often it occurs Always Usually Sometimes Never How much it bothers you Extremely Very much Moderately A little Not at all How often it occurs Always Usually Sometimes Never How much it bothers you Extremely Very much Moderately A little Not at all Notes Not at all How often it occurs Always Usually Notes Behavior first noted? Moderately Notes Behavior first noted? How much it bothers you Extremely Very much Notes Behavior first noted? Never Notes Behavior first noted? Sometimes http://www.amazon.com/Alzheimers-Caregivers-Guide-Sourcebook-Edition/dp/0471379670/ref=sr_1_fkmr0_2?ie=UTF8&qid=1360259358&sr=8-2-fkmr0&keywords=alzheimer% 27s+caregiver+resource+guide Notes Behavior first noted? How often it occurs Always Usually Buy the book here: Behavior first noted?

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