PD COMM Trial Participant
Trial No: __ __ __ __ __
DOB: DD/M M M / Y Y Y Y
Initials: __ __ __
Standard NHS SLT
Home Based Therapy (HBT) Diary
For completion by therapist:
Was home based therapy prescribed? Y / N (please circle)
What was the date of the session that the HBT is prescribed/not prescribed in (dd/mmm/yyyy): DD / M M M / Y Y Y Y
Is this the last home based therapy form to be expected? Y / N (please circle)
Participant Completion Guidelines:
Your therapist may ask you to complete some home based therapy tasks, these are described in the blue columns in the table on the following page.
Please record whether you practiced these tasks in the yellow columns on the following page. Please indicate the number of minutes or repetitions (as
prescribed by your therapist) you spent on the task each day. e.g. 3 mins for time or 10 reps for number of repetitions.
At the bottom of the table, please can you confirm whether the exercises where performed when you were “on” your PD medications.
Please complete one form for each week that you practise exercises prescribed by you Speech & Language therapist.
If you do not attempt some parts of your Home Based Therapy (HBT), please complete that box as N/D (Not done).
If some information is missing and you do not know the answer, please complete that box as UNK (Unknown).
Please answer all questions in each column even if they are N/D (Not done).
Please bring your completed form to your next therapy session and give it to your SLT.
Speech and Language Therapist Completion Guidelines (for more detailed guidelines, see page 3):
o Please complete a form for each week of home based therapy prescribed.
o Record any home based therapy tasks in the blue column.
o The study participant with PD completes the yellow section.
Confidential Once Completed
IRAS Number 188505
NHS Standard HBT Diary, version 2.0 04.05.2016
Tasks prescribed
1.
Expected
Time/Reps
to be
performed
per day
Prescribed
intervention
treatment
focus (see
table for
reference)
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
3.
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
4.
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
5.
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
Reps:___
Time:___
(mins)
1 [ ], 2 [ ],
3 [ ], 4 [ ],
5 [ ], 6 [ ]
2.
6.
Date of HBT
Date of HBT
Date of HBT
Date of HBT
Date of HBT
Date of HBT
Date of HBT
dd/mmm/yy
dd/ mmm /yy
dd/ mmm /yy
dd/ mmm /yy
dd/ mmm /yy
dd/ mmm /yy
dd/ mmm /yy
Did you have a speech and language therapy appointment today?
Name of therapist:
Y/N
Y/N
Please circle
Please circle
Y/N
Y/N
Please circle
Please circle
Y/N
Please circle
Y/N
Please circle
Y/N
Please circle
Was your home based therapy performed when you were “on” state?
Y/N
Please circle
Y/N
Please circle
Y/N
Not Done = N/D,
Confidential Once Completed
IRAS Number 188505
Y/N
Please circle
Please circle
Y/N
Please circle
Y/N
Please circle
Y/N
Please circle
Unknown = UNK
NHS Standard HBT Diary, version 2.0 04.05.2016
Speech and Language Therapist Completion Instructions:
Please ensure that you complete the front page information and the pale blue section of this form (even if to indicate no practice at home has been prescribed).
All questions on the front page will be queried if not complete, please ensure all questions are answered before returning the form to the Birmingham Clinical Trials Unit.
Tasks prescribed
Please describe here any tasks that you have asked the person with PD to complete over the week. If relevant, include the number of times per week they are expected to
be completed. If you have prescribed more than 7 tasks for the week, please use an additional NHS HBT diary form to record this information.
Expected Time/Reps to be performed per day
Please complete the number of repetitions to be performed or the amount of time (in minutes) required for each task prescribed. Please ensure you define if you are using
number of repetitions or a set number of minutes for the exercise.
Prescribed intervention
Using the table below, please enter the value (or values) that best describe the task that is to be performed. Please note more than one value can be assigned per task.
Prescribed
intervention code
number
Prescribed intervention
treatment focus
Examples
1
Breathing control
Diaphragm breathing, Breathing exercises, Pacing/rate control, Relaxation
2
Voice quality
Breath support, Loudness, Voice exercises, Relaxation
3
Intelligibility
Pacing/rate control, Loudness, Articulation exercises, Breath control
4
Language
Word finding strategies, Work with carers, Advice, Compensation/circumlocution, Memory activities
5
Augmentative & Alternative
Communication
Amplifiers, Light writer, Communication aids, Alphabet charts, Communication Alphabet charts,
Communication books
6
Other
Prescribed task which does not fit the above groupings, please describe in the ‘other’ section.
Name of therapist
Please confirm the name of the therapist that set the home based therapy for the participant.
PD COMM is funded by the National Institute for Health Research's HTA Programme. Managed by the Birmingham Clinical Trials Unit (BCTU).
Sponsored by the University of Birmingham. www.birmingham.ac.uk/BCTU
PD COMM has received approval from the Coventry & Warwick Multi-centre Research Ethics Committee and approval of the Research and
Development Department relating to your Health Trust, Hospital and Consultant.
Confidential Once Completed
IRAS Number 188505
NHS Standard HBT Diary, version 2.0 04.05.2016