CASE HISTORY TEMPLATE

This is a suggested template and starting point for therapists conducting CST in senior care settings. It is a work in progress and we welcome your input and suggestions for improvement. Whether it be in small settings or large institutions, our intent is to record this information, using this format as a beginning point for followup research.

Case History Template

Name/ID #
Location
Diagnosis
Type of Care (i.e. short term, long term, assisted living, skilled nursing, etc.)
Beginning date:
Ending date:

Observations:
Wk 1
Wk 3
Wk 6
Wk 9
Wk 12
Wk 18
Wk 24

Notes: