Resident____________________________ | Medical Record#_____________ | Room________ | ||||
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| MOOD AND BEHAVIOR PATTERNS DURING THE THREE MONTH PERIOD ___/___/___ to ___/___/___ | Behavior occurs 1-3 times per/week | Behavior occurs 4-6 times per/week | Behavior occurs 6-7 times per/week |
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| Be sure to rate every item with an X | | | |
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| 1. Verbally expression of sadness, hopelessness, or negative statements | | | |
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| 2. Asking same questions constantly | | | |
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| 3. Making same statements repetitively | | | |
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| 4. Easily angered, irritable, or easily frustrated | | | |
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| 5. Making derogatory statements about self | | | |
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| 6. Expression of unrealistic fears | | | |
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| 7. Belief that something terrible is about to happen | | | |
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| 8. Making numerous complaints about health | | | |
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| 9. Constantly seeking attention and reassurance regarding care and nursing treatment | | | |
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| 10. Unable to get to sleep | | | |
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| 12. Very restless sleep or intermittent awakenings during night | | | |
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| 13. Unpleasant mood in morning | | | |
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| 14. Sad or worried facial expression | | | |
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| 15. Crying episodes | | | |
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| 16. Repetitive movements such as pacing, wringing hands, restlessness, or picking | | | |
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| 17. Have lost interest in others and withdrawn | | | |
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| 18. Expressed thoughts of wanting to die | | | |
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| 19. Exhibiting disruptive behavior | | | |
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| 20. Memory problem or poor concentration | | | |
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| 21. Tired or have loss of energy | | | |
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| 22. Sudden episodes of nervousness or panic | | | |
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| 23. Fear of losing control | | | |
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| 24. Very anxious in social situations | | | |
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| 25. Expresses belief someone is trying to harm him/her or is making life especially difficult | | | |
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| 26. Ritualistic or obsessive behaviors | | | |
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| 27. Wandering aimlessly | | | |
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| 28. Verbally abusive behavior | | | |
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| 29. Physically abusive to others | | | |
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| 30. Resists personal care | | | |
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| 31. Sense (hear, see, smell, touch, taste, or feel) things that others can’t | | | |
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Source : http://www.cncplan.com/moodmonitor.htm