Patient name
Week of (start date)
Week of (end date)
Completed by
HOW TO USE — Mark each behaviour when it occurs: M=Mild · S=Significant · write time of day in the cell
Severity key:
Mild — brief, resolved easily
Moderate — needed intervention
Significant — distressing or unsafe
| Behaviour | Mon | Tue | Wed | Thu | Fri | Sat | Sun | Total |
|---|---|---|---|---|---|---|---|---|
| Agitation / restlessness | ||||||||
| Wandering / exit-seeking | ||||||||
| Sundowning (eve. confusion) | ||||||||
| Repetitive questions/actions | ||||||||
| Paranoia / accusation | ||||||||
| Refusal of personal care | ||||||||
| Aggression (verbal) | ||||||||
| Aggression (physical) | ||||||||
| Confusion about time/place | ||||||||
| Sleep disturbance | ||||||||
| Fall or near-miss | ||||||||
| Medication refusal | ||||||||
| Food / fluid refusal | ||||||||
| Other (describe below) |
TRIGGER NOTES — When behaviours occurred, what may have caused them, and what helped
| Behaviour | Possible trigger / context | What was tried | What helped / didn't help |
|---|---|---|---|
WEEKLY SUMMARY
Behaviours that increased this week
Behaviours that decreased or improved
Patterns noticed (time of day, triggers)
What worked well this week
What to try differently next week
Items to raise with doctor or care team
Tip: Bring this tracker to every doctor appointment — patterns visible across a week are far more useful than impressions. A new or worsening behaviour (especially sudden agitation or confusion) can signal a UTI or other treatable physical cause. Always rule out pain or infection first. · gurjotnarwal.com/how-i-can-help