Language
English (US)
Spanish (Latin America)
Date & Time
Staff Filling Out Form
First Name
Last Name
What Was Your Shift Hours Today?
Health & Safety
Tracking My Goals ... Let's Go!
If no, why not?
If yes, what topical was applied? How many times per day was this topical applied?
Type your answer here
If yes, what did Kyle do for exercise and where did Kyle exercise?
Type your answer here
If no, what prevented Kyle from exercising today?
Example: bad weather, kyle chose not to exercise, etc.
If yes, where did Kyle go shopping, what did Kyle purchase?
Type your awnser above
If yes, comments on activity?
Type your awnser above
If yes, please explain?
Example: Kyle fell, etc.
If yes, please explain?
Example: Kyle fell, etc.
If no, please explain?
Example: Kyle fell, etc.
If yes, how long did the seizure last?
Example: Kyle fell, etc.
If yes, please explain?
Example: Kyle fell, etc.
If yes, please explain?
Example: Kyle fell, etc.
Social Relationships & Community Integration
Tracking My Goals ... Let's Go!
Kyle's Signature
Clear
Staff's Signature
Clear
Detected Location
Any Additional Comments to Add to Your Day?
Should be Empty: