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Activity Assessment
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Sample Activity Assessment Form

Activity Assessment

Name- Nickname-
Date- Age-
Birthdate- Religion-
Spouses Name- Anniversary-
Spouses Occupation-
City/State resident spent majority of time-
Education- Military-
Past clubs/volunteer affiliations-
Favorite Color-
Favorite Foods-
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-


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Jolene Ewert, All Rights Reserved