LEISURE INTEREST SURVEY - Temple University



[pic] LEISURE INTEREST SURVEY

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|Name: |Age: |Date: |

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|Recreation Therapist: |Parent/Guardian/Staff: |

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|Please mark an "x" next to the activities that best describe your community leisure interests. |

|Additional items may be added to the list according to your interests. |

|ACTIVITY |HAVE DONE |CURRENTLY DO |INTERESTED |

| |IN PAST | |IN DOING |

|Engaging in Team Sports |

|Basketball | | | |

|Softball/Baseball | | | |

|Soccer | | | |

|Football | | | |

|Hockey | | | |

|Bowling | | | |

|Volleyball | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Engaging or Observing Individual Sports |

|Jogging/Running | | | |

|Swimming | | | |

|Bike Riding | | | |

|Walking | | | |

|Tennis/Ping Pong | | | |

|Darts | | | |

|Golf | | | |

|Badminton | | | |

|Croquet | | | |

|Bocce | | | |

|Horseback Riding | | | |

|Fishing | | | |

|Gymnastics | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Music |

|Singing | | | |

|Playing Instrument | | | |

|Attending Concerts | | | |

|Listening to Radio/Stereo | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|ACTIVITY |HAVE DONE |CURRENTLY DO |INTERESTED |

| |IN PAST | |IN DOING |

|Dance |

|Country | | | |

|Folk | | | |

|Square | | | |

|Aerobic | | | |

|Yoga | | | |

|Tap/Ballet/Jazz | | | |

|Rock n' Roll | | | |

|Line Dancing | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Arts and Crafts |

|Painting/Drawing | | | |

|Knitting | | | |

|Sewing | | | |

|Crocheting | | | |

|Latch Hook | | | |

|Embroidery | | | |

|Weaving | | | |

|Ceramics/Pottery | | | |

|Woodworking | | | |

|Jewelry Making | | | |

|Baking/Cooking | | | |

|Photography | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Table Games |

|Cards | | | |

|Checkers | | | |

|Chess | | | |

|Dominoes | | | |

|Scrabble | | | |

|Puzzle | | | |

|Billiards | | | |

|Bingo | | | |

|Board Game (please specify): | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Outdoor Leisure/Social |

|Hiking/Climbing | | | |

|Walking | | | |

|Gardening | | | |

|Camping | | | |

|Barbecues/Picnics | | | |

|Skiing/Sledding | | | |

|ACTIVITY |HAVE DONE |CURRENTLY DO |INTERESTED |

| |IN PAST | |IN DOING |

|Outdoor Leisure/Social (continued) |

|Canoeing | | | |

|Fishing | | | |

|Roller Skating/Roller Blading | | | |

|Ice Skating | | | |

|Bicycling | | | |

|Swimming | | | |

|Boating | | | |

|Lawn Games | | | |

|Beach | | | |

|Nature Study | | | |

|Weather Observation | | | |

|Bird Watching | | | |

|Amusement Parks/Fairs | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Community Activities/Entertainment |

|Historical | | | |

|Sporting Events | | | |

|Shopping | | | |

|Dining Out | | | |

|Library | | | |

|Aquarium | | | |

|Museums | | | |

|Concerts | | | |

|Hometown Events | | | |

|Recreation/Community Center | | | |

|Flea Markets | | | |

|Sightseeing | | | |

|Parades | | | |

|Video Games | | | |

|Collecting (stamps, rocks, etc.) | | | |

|Religious Services | | | |

|Auto Racing | | | |

|Boxing/Wrestling | | | |

|Spectator Sports (please specify): | | | |

|Movies | | | |

|Television | | | |

|Visit/Entertain Friends/Family | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Social Clubs/Organizations |

|Cultural Ethnic | | | |

|Cooking | | | |

|Card Playing | | | |

|Senior Citizens | | | |

|Religious | | | |

|Other (please specify): | | | |

|ACTIVITY |HAVE DONE |CURRENTLY DO |INTERESTED |

| |IN PAST | |IN DOING |

|Literacy/Continuing Education |

|Reading (books, magazines, etc.) | | | |

|Computers | | | |

|Letter Writing | | | |

|Adult Education Classes | | | |

|Computer Education | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

|Volunteer Work |

|Political Campaign | | | |

|Homeless Shelter | | | |

|Food Co-Op/Food Bank/SHARE | | | |

|Special Olympics | | | |

|Nursing Homes | | | |

|Recycling | | | |

|Other (please specify): | | | |

|Other (please specify): | | | |

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|NOTES |

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