1: Logistics
• Resident Name:
• LOA Dates (Out - In):
• Caregiver Name & Relationship:
💊 2: Medical & Safety
• Meds given exactly as scheduled?
o Options: Yes, No (Specify below)
• If No / New meds added, details:
• Primary Mood Behavior:
o Options: Stable, Anxious/Elevated, Depressed/Withdrawn, Fluctuating
• Safety Flags (Select all that apply):
o Options:
⚠️ Self-harm/Suicidal thoughts
🚨 Aggression / Agitation
🧠 Confusion / Hallucinations
❌ None / No concerns
📝 3: Physical & Signs
• Any injuries, falls, or physical illnesses?
o Options: No, Yes (Specify below)
• Physical health / Substance concerns: