To help the doctor keep track of how your loved one is doing, use this Observation Log.
Before an appointment with your doctor, please fill out an Observation Log based on your most recent observations of your loved one.
Only a few minutes are needed to complete this form, but it will encourage clear communications between the doctor and you.
The Observation Log gives your doctor an update of your loved one's condition quickly, to make the most of your office visit. It will also help your doctor measure how effective the current treatment is, and decide if any adjustments are necessary.
Instructions:
Please place a tick inthe appropriate column to inform the doctor of changes observed in your loved one since the last visit or last dose adjustment. At the bottom, do the same to indicate how these changes have affected you. if not applicable or can't assess, check "No noticeable change from usual".
NOTE: No change, improvement, or even minimal decline are all positive signs of treatment effectiveness.
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No noticeable change
Slight change
Significant change
Daily activities:
Bathing, using the bathroom, grooming, dressing
Eating habits, manners
Sleeping patterns
Ability to use household appliances
Behaviour:
Motivation to do things, general mood,
cooperativeness
Anxiety level, restlessness, agitation, pacing
Social:
Participation in conversation, recognising
family/friends
Engaging in social activities, interest in hobbies
and leisure activities
Thinking/memory:
Remembering names/events, ability to find appropriate
words
Keeping track of time, awareness of environment,
ability to follow instructions
Impact on caregiver:
Depression, inability to cope, anger/frustration with
your loved one
Inability to sleep through the night
Interference with your ability to work or participate
in social activities
For more information visit:
Dementia SA: http://www.dementiasa.org/ or Alzheimer’s South Africa: http://www.alzheimers.org.za/
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