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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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