Activity Assessment Name- Nickname- Date-
Age- Birthdate- Religion- Occupation- Spouses Name-
Anniversary- Spouses Occupation- Hometown- City/State resident spent majority of time- Hobbies- Education-
Military- Past clubs/volunteer affiliations- Favorite Color- Favorite Foods-
Pets- Children Age Occupation Grandchildrens Names and Ages
Sisters and Brothers and Ages Special Memories- How can we make this resident feel welcome
and comfortable at our facility?
Describe a typical daily routine for
this resident- List some of the residents likes and dislikes- List any special needs or medical
concerns- Any special dietary needs? Please circle the activities in which resident might be interested:
Puzzles Movies Pets Outings Parties
Games Music Gardening Cooking
Crafts Exercise Lifeskills Reading/Poetry Current Events List
some other interests not included above- Comments-
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