Alzheimer's Disease Daily Monitoring Log

Patient Information

Name: ____________________ Date of Birth: //____ Caregiver Name: ____________________ Contact: ____________

Daily Activities Tracking

Cognitive Function

• Memory Issues (circle): None | Mild | Moderate | Severe
• Confusion Episodes: Time(s) _______ Duration _______
• Language Difficulties (check all): □ Word finding □ Comprehension □ Speech clarity

Activities of Daily Living

• Personal Hygiene: □ Independent □ Needed Help □ Unable
• Dressing: □ Independent □ Needed Help □ Unable
• Eating: □ Independent □ Needed Help □ Unable
• Mobility: □ Independent □ Needed Help □ Unable

Behavioral Symptoms

• Agitation Level: □ None □ Mild □ Moderate □ Severe
• Sundowning: □ Yes □ No
• Time of Day When Symptoms Worsen: _______

Medication Adherence

Morning Medications: □ Taken □ Refused □ N/A Afternoon Medications: □ Taken □ Refused □ N/A Evening Medications: □ Taken □ Refused □ N/A

Sleep Pattern

Hours Slept: _____ Quality (1-5): _____ Naps During Day: □ Yes □ No Duration: _____

Notes

Mood Changes: ________________________________________ Unusual Events: ______________________________________

Weekly Summary

Changes from Last Week: _______________________________ Concerns to Discuss with Doctor: _______________________

Date Completed: //____ Caregiver Signature: __________________