Behavior Changes

  • Behavior Changes

    For caregivers to complete. Form time: less than 2 min

  • Understanding underlying causes for behavior concerns

    If you are concerned about an emergency event, like a stroke, do not complete this form and contact 911 or your primary care team

  • Date of birth of the person living with dementia or cognitive decline
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  • Date
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  • Which of the following concern(s) currently exist? Please select all that apply.*
  • How long has this concern(s) been going on?*
  • What is the severity and frequency of the behavior(s) from 0-4? If the severity and frequency are different, pick the higher score (e.g a behavior that is daily but mild, pick the 4 score)*
  • Do you notice any of the following unsafe behaviors? (Check all that apply.)*
  • What is the severity and frequency of these additional behavior(s) from 0-4? If the severity and frequency are different, pick the higher score (e.g a behavior that is daily but mild, pick the 4 score)*
  • Do any of these behaviors negatively affect the individual's relationships, activities, or willingness to receive care?
  • What changes in urination exist? Choose all that apply.*
  • Does the person show any of these constipation signs? Choose all that apply.*
  • Does the person show any of these pain signs? Choose all that apply.*
  • Oftentimes, changes in behavior are triggered by changes in the home environment. Do any of the following changes apply to the person with dementia? Choose all that apply.
  • Any medication or over-the-counter medication changes in the prior 1 month?*
  • What interventions have you tried for this concern(s)? There is no problem if you haven't tried any of the following and some of these choices may not be relevant! Choose all that apply.*
  • Should be Empty: