Initial Activity Assessment sheet

[Pages:4]Initial Activity Assessment _____________ ______

Name:

Med record #

Sex: M F DOB: _______________ Birthplace: __________________________________________ Marital Status: M W S D Family Info: # of children ____ # of grandchildren ____ # of great grandchildren: ____ # of step-children:____ # step-grand:_____ Significant other:____________________________ Res. Relationship with family: _______________ Registered voter:__________ Veteran: _____ Branch & date: ________________ Spouse in service: ____ Branch & date: ________________________________ Religious affiliation: _________________________ Personal Involvement: _____________________________________________ Education level: ____________________________Ability to read: _____ Ability to write: _____ Other Language:______________ Past occupations & jobs: ______________________________________________________________________________________ Organizational involvement: ___________________________________________________________________________________ __________________________________________________________________________________________________________ Hand dominance: Left Right Tobacco user: ______ Kind: _______________ How much: _________________ When last used: ___________________________ Alcohol user: ______ Kind: _______________ How much: _________________ When last used: ___________________________

Interest Survey

Blue = past interests

Notes: _____________________________________________

Yellow = current interests ___________________________________________________

Games

Crafts

Outing

Just for Fun

Television

Reading

Movies

Bingo Checkers

Chess Backgammon

Dominoes Monopoly Scrabble Yahtzee _____________ _____________

Cards

Bridge Canasta

Gin Uno Pinochle Poker Euchre Rummy Solitaire ______________ ______________

Ceramics Crocheting Doll making Glass blowing Hooking rugs

Knitting Leather working

Needlepoint Plastic craft Scrap booking Stained glass Woodworking Embroidery

Quilting

Exercise

Aerobic Stretching Walking Jogging Swimming

Gardening

Pets

Dog Cat Fish Birds

Flowers Vegetables

Shrubs House plants

Cactus _____________

Ballgames Fishing Museums Parks Zoos Shopping Van rides Lunches

Music

Classical Country Gospel

Jazz Big band 30's & 40's 50's & 60's Rhythm Rock & roll Heavy metal

Rap Easy listening

Puzzles

Crossword Jigsaw

Word search Word scramble

Parties Picnics Plays Music programs

Household

Cleaning Laundry Dish washing Cooking Baking Decorating ______________ ______________

Sports

Baseball Basketball Football Bowling

Fishing Hunting Hockey Horseshoes Ring toss Volleyball ______________ ______________

News Sports Soaps Games Movies Cartoons Comedy Adventure Drama Old TV Wrestling Reality TV

Cable TV

MTV HGTV Food Channel CNN

Computer

Games Internet

Writing

Poetry Letters Haiku Short stories

Autobiographies

Comedy

Fiction

Drama

Historical

Musical

Nonfiction

Westerns

Fiction

War

Religious

Sci-fi

Science fiction

Disney

Westerns

40's & 50's

Mystery

John Wayne

Newspaper ______________

Poetry

______________

Romance ______________

Magazines ______________

Bible

Instruments

Art

Piano

Oil painting

Organ

Sculpture ______________

Watercolors ______________

Drawing ______________

Chalks

Poly clay

Other

Sewing

Mending Clothing ______________ ______________

Travel Genealogy Dancing Collecting: _____________ Automotive Construction

NOTES:___________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ May we invite family & friends to facility functions? YES NO Information provided by: Resident____ Other (name): ________________________________ Relationship: __________________

Date: _________________ Assessor: ___________________________________________________________________________

Initial Activity Assessment

Name:____________________________MedRec#__________

Admission Date: ____________________________________________________________________________________________ Admitted From: ___________________________________________________________Physician: ________________________ Allergies: __________________________________________________________________________________________________ Diagnosis: _________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Physical Assessment

Therapy:

Mode of Expression: Diet:

Vision:

Physical_____________ Speech______________ Regular_____________ Adequate____________

Occupational_________ Writing_____________ NCS_______________ Impaired____________

Speech______________ Gestures/sounds______ NAS_______________ Moderately impaired__

Oxygen_____________ Communication board_ Mec. Soft___________ Highly impaired______

Special treatments:____ ____________________ Pureed______________ Severely impaired_____

____________________ __________________ Tube feed___________ Glasses_____________

__________________

NPO_______________ ___________________

Being Understood:

Thickened liquids_____

Personal Safeguards: Understood

Other: ______________ Hearing:

Wander Guard_______ Usually

____________________ Adequate____________

Personal Alarm_______ Sometimes

____________________ Minimal difficulty____

Posey Hugger________ Rarely/never

____________________ Special situations_____

Bed Alarm__________ ____________________ ____________________ Highly impaired______

Low Bed____________ ____________________ ____________________ Hearing aid__________

___________________ _________________ ______________

___________________

Permission to: Open/read mail_______ Use beauty shop______ Put name in newsletter_ Photograph__________ Go on facility outing___ Do shopping for resident._______________

Amb/mode transport: Independent_________ Wheels self__________ Help wheel__________ Cane_______________ Walker_____________ Wheelchair__________

Annual Activity Assessment

Resident:___________________________________________ Medical Record #: ________________________Date:___________

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

X = Yes

Mode of Expression: Vision:

Diet:

Permission to:

Speech______________ Adequate____________ Regular_____________ Open/read mail_______

Hand dominance: R L Registered to vote:____ Marital Status:

M W S D Ability to:

Read__________ Write_________

Writing_____________ Moderately impaired__ NCS_______________

Gestures/sounds______ Highly impaired______ NAS_______________

Communication board_ Severely impaired_____ Mec. Soft___________

____________________ Glasses_____________ Pureed______________

____________________ ___________________ Tube feed___________

____________________ ____________________ NPO_______________

____________________ __________________ Thickened liquids_____

_______________

Other: ______________

Use beauty shop______ Put name in newsletter_ Photograph__________ Go on facility outing___ Do shopping for resident._______________ ____________________ __________________

Religious affiliation: __ ___________________ Being Understood:

Understood

Hearing:

___________________

Adequate____________

Amb/mode transport:

Minimal difficulty____ Personal Safeguards: Independent_________

Therapy:

Usually

Special situations_____ Wander Guard_______ Wheels self__________

Physical_____________ Sometimes

Highly impaired______ Personal Alarm_______ Help wheel__________

Occupational_________ Rarely/never

Hearing aid__________ Posey Hugger________ Cane_______________

Speech______________ ____________________ ____________________ Bed Alarm__________ Walker_____________

Oxygen_____________ ____________________ ____________________ Low Bed____________ Wheelchair__________

Special treatments:____ ____________________ ____________________ ____________________ ____________________

____________________ ____________________ ________________

____________________ ____________________

__________________ _______________

_________________ _________________

Annual Interest Survey Blue = past interests Yellow = current interests

Games

Crafts

Outing

Just for Fun

Television

Reading

Movies

Bingo Checkers

Chess Backgammon

Dominoes Monopoly Scrabble Yahtzee _____________ _____________

Cards

Bridge Canasta

Gin Uno Pinochle Poker Euchre Rummy Solitaire ______________ ______________

Ceramics Crocheting Doll making Glass blowing Hooking rugs

Knitting Leather working

Needlepoint Plastic craft Scrap booking Stained glass Woodworking Embroidery

Quilting

Exercise

Aerobic Stretching Walking Jogging Swimming

Gardening

Pets

Dog Cat Fish Birds

Flowers Vegetables

Shrubs House plants

Cactus _____________

Ballgames Fishing Museums Parks Zoos Shopping Van rides Lunches

Music

Classical Country Gospel

Jazz Big band 30's & 40's 50's & 60's Rhythm Rock & roll Heavy metal

Rap Easy listening

Puzzles

Crossword Jigsaw

Word search Word scramble

Parties Picnics Plays Music programs

Household

Cleaning Laundry Dish washing Cooking Baking Decorating ______________ ______________

Sports

Baseball Basketball Football Bowling

Fishing Hunting Hockey Horseshoes Ring toss Volleyball ______________ ______________

News Sports Soaps Games Movies Cartoons Comedy Adventure Drama Old TV Wrestling Reality TV

Cable TV

MTV HGTV Food Channel CNN

Computer

Games Internet

Writing

Poetry Letters Haiku Short stories

Autobiographies

Comedy

Fiction

Drama

Historical

Musical

Nonfiction

Westerns

Fiction

War

Religious

Sci-fi

Science fiction

Disney

Westerns

40's & 50's

Mystery

John Wayne

Newspaper ______________

Poetry

______________

Romance ______________

Magazines ______________

Bible

Instruments

Art

Piano

Oil painting

Organ

Sculpture ______________

Watercolors ______________

Drawing ______________

Chalks

Poly clay

Other

Sewing

Mending Clothing ______________ ______________

Travel Genealogy Dancing Collecting: _____________ Automotive Construction

Activity Participation Summary Key: Date_______ Daily = D Weekly = W Monthly = M

Activity

Attend

Activity

Attend

Activity

Attend

? Coffee club

____ ? Bible study

_____ ? 1:1 visits

? Music club

____ ? Church--Sun. _____ ? comforting

? Price is right

____ ? Church--Thr. _____ ? passive

? Saturday cartoons ____ ? Mass

_____ ? friendly

? Bingo

____ ? Church specials _____ ? music

? Fancy nails

____ ? Men's breakfast _____ ? TV

? Popcorn

____ ? Holiday specials _____ ? Independent

? Movies ? Social

____ ____ ____

? ?

Birthday party Newsletter prep

_____ _____

?

_____

? Music program ? Cooking club

____ ? ____ ?

Special meals Order out lunch

_____ _____

NOTES:

? Resident Council ____ ? Lunch out

_____

? Yahtzee

____ ? Outing

_____

? Card games

____ ? Van rides

_____

? Trivia

____ ? Cookie sales

_____

? Hangman

____ ? Fund raiser

_____

? Proverbs

____ ? Kids Kare

_____

? Derby day

____ ? Resident Shop- _____

? Mystery auction ____

ping

? Bible Quiz

____ ? Smoking

? Communion Srvc. ____ ? Beauty shop

_____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____

Care Plan Review

Date: _______________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

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