Date
Day of week
Caregiver name
Shift hours (e.g. 7am – 3pm)
MOOD & ENERGY — circle one number for each (1 = very low 3 = ok 5 = great)
Morning mood
1 · 2 · 3 · 4 · 5
Afternoon mood
1 · 2 · 3 · 4 · 5
Evening mood
1 · 2 · 3 · 4 · 5
Sleep quality (previous night)
1 · 2 · 3 · 4 · 5
Energy level today
1 · 2 · 3 · 4 · 5
Pain level (0 = none, 5 = high)
0 · 1 · 2 · 3 · 4 · 5
DAILY TASKS — tick the column that applies
| Task | ✓ Done | Refused | Assisted | N/A | Notes |
|---|---|---|---|---|---|
| Morning hygiene (wash, brush teeth) | ☐ | ☐ | ☐ | ☐ | |
| Shower / bath | ☐ | ☐ | ☐ | ☐ | |
| Dressing (appropriate for weather) | ☐ | ☐ | ☐ | ☐ | |
| Breakfast | ☐ | ☐ | ☐ | ☐ | |
| Morning medications | ☐ | ☐ | ☐ | ☐ | |
| Lunch | ☐ | ☐ | ☐ | ☐ | |
| Afternoon activity | ☐ | ☐ | ☐ | ☐ | |
| Dinner | ☐ | ☐ | ☐ | ☐ | |
| Evening medications | ☐ | ☐ | ☐ | ☐ | |
| Evening hygiene | ☐ | ☐ | ☐ | ☐ | |
| Bedtime routine | ☐ | ☐ | ☐ | ☐ |
MEALS & FLUIDS
| Meal | What was eaten | Amount eaten (all / half / little / refused) | Fluids (cups) |
|---|---|---|---|
| Breakfast | |||
| Lunch | |||
| Dinner | |||
| Snacks |
BEHAVIOUR OBSERVATIONS — tick any that occurred today
☐ Agitation / restlessness
☐ Wandering / exit-seeking
☐ Sundowning (evening confusion)
☐ Repetitive questions or actions
☐ Paranoia / accusation
☐ Refusal of personal care
☐ Aggression (verbal or physical)
☐ Confusion about place or time
☐ Fall or near-miss (describe below)
☐ Unusual behaviour (describe below)
Triggers / what helped
ACTIVITIES & EXERCISE
| Activity | Duration | How did they respond? (engaged / resistant / neutral / enjoyed) |
|---|---|---|
| Physical (walk, stretches, chair exercises…) | ||
| Cognitive (music, puzzles, reading, reminiscing…) | ||
| Social (visitor, phone/video call, group…) |
END OF SHIFT & HANDOFF
Overall: how was today?
☐ Good day ☐ Difficult day ☐ Mixed
Handoff notes
Anything the next caregiver or family member must know about today…
Caregiver signature
Time completed
Reviewed by (family member)