Dementia Behavior Tracking Form
Use this form to record and monitor dementia-related behaviors, possible triggers, responses, and follow-up actions.
Observation Details
Date of Observation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Observation
*
Hour Minutes
AM
PM
AM/PM Option
Person Observed
*
First Name
Last Name
Observer Name
*
First Name
Last Name
Observer Role
*
Location of Behavior
*
Observation Type
*
Initial Incident
Follow-up Observation
Behavior Description
Behavior Category
*
Agitation
Aggression
Wandering
Repetition
Resistance to Care
Sleep Disturbance
Hallucinations/Delusions
Other
Detailed Description of Behavior
*
Observed Triggers or Antecedents
Duration of Behavior
Log Multiple Behaviors
Severity and Response
Severity / Intensity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Immediate actions taken
Reassurance provided
Redirection attempted
Removed trigger/stressor
Provided space/time
Contacted caregiver/staff
Monitored closely
Other
De-escalation or support strategies used
Calm voice
Active listening
Validation
Distraction or activity change
Simplified instructions
Offered food or drink
Physical comfort item
One-to-one support
Other
Response afterward
Calmed down
Partially improved
No change
Worsened
Needed further support
Other
Follow-up and Notes
Family or care team notified?
*
Yes
No
Pending
Recommended follow-up actions
Schedule review
Increase monitoring
Update care plan
Contact primary clinician
Review medications
Other
Monitoring plan
Additional notes
Submit
Should be Empty: