Read Initial Activity Assessment sheet text version

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

Games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yahtzee _____________ _____________ Cards Bridge Canasta Gin Uno Pinochle Poker Euchre Rummy Solitaire ______________ ______________ Pets Dog Cat Fish Birds Crafts 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

Blue = past interests Yellow = current interests

Notes: _____________________________________________ ___________________________________________________ Television 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 Reading Autobiographies Fiction Historical Nonfiction Fiction Religious Science fiction Westerns Mystery Newspaper Poetry Romance Magazines Bible Art Oil painting Sculpture Watercolors Drawing Chalks Poly clay Sewing Piano Organ ______________ ______________ ______________ Other Movies Comedy Drama Musical Westerns War Sci-fi Disney 40's & 50's John Wayne ______________ ______________ ______________ ______________ Instruments

Outing 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

Just for Fun 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 ______________ ______________

Flowers Vegetables Shrubs House plants Cactus _____________

Crossword Jigsaw Word search Word scramble

Travel Genealogy Mending Dancing Clothing 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: Physical_____________ Occupational_________ Speech______________ Oxygen_____________ Special treatments:____ ____________________ __________________ Personal Safeguards: Wander Guard_______ Personal Alarm_______ Posey Hugger________ Bed Alarm__________ Low Bed____________ ___________________ Diet: Regular_____________ NCS_______________ NAS_______________ Mec. Soft___________ Pureed______________ Tube feed___________ NPO_______________ Thickened liquids_____ Being Understood: Other: ______________ Understood ____________________ Usually ____________________ Sometimes ____________________ Rarely/never ____________________ ____________________ ____________________ ____________________ ______________ _________________ Mode of Expression: Speech______________ Writing_____________ Gestures/sounds______ Communication board_ ____________________ __________________ Vision: Adequate____________ Impaired____________ Moderately impaired__ Highly impaired______ Severely impaired_____ Glasses_____________ ___________________ Hearing: Adequate____________ Minimal difficulty____ Special situations_____ Highly impaired______ 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:___________

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

Mode of Expression: Speech______________ Hand dominance: R L Writing_____________ Registered to vote:____ Gestures/sounds______ Communication board_ Marital Status: ____________________ M W S D ____________________ Ability to: Read__________ ____________________ Write_________ ____________________ _______________

X = Yes

Vision: Adequate____________ Moderately impaired__ Highly impaired______ Severely impaired_____ Glasses_____________ ___________________ ____________________ __________________ Hearing: Adequate____________ Minimal difficulty____ Special situations_____ Highly impaired______ Hearing aid__________ ____________________ ____________________ ____________________ ________________

Religious affiliation: __ ___________________ Therapy: Physical_____________ Occupational_________ Speech______________ Oxygen_____________ Special treatments:____ ____________________ __________________

Diet: Regular_____________ NCS_______________ NAS_______________ Mec. Soft___________ Pureed______________ Tube feed___________ NPO_______________ Thickened liquids_____ Other: ______________ ___________________ Personal Safeguards: Wander Guard_______ Personal Alarm_______ Posey Hugger________ Bed Alarm__________ Low Bed____________ ____________________ ____________________ _________________

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__________ ____________________ ____________________ _________________

Being Understood: Understood Usually Sometimes Rarely/never ____________________ ____________________ ____________________ ____________________ _______________

Annual Interest Survey

Games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yahtzee _____________ _____________ Cards Bridge Canasta Gin Uno Pinochle Poker Euchre Rummy Solitaire ______________ ______________ Pets Dog Cat Fish Birds Crafts 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 Puzzles Flowers Vegetables Shrubs House plants Cactus _____________ Outing 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

Blue = past interests Yellow = current interests

Just for Fun 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 ______________ ______________

Television 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

Reading Autobiographies Fiction Historical Nonfiction Fiction Religious Science fiction Westerns Mystery Newspaper Poetry Romance Magazines Bible Art Oil painting Sculpture Watercolors Drawing Chalks Poly clay Sewing

Movies Comedy Drama Musical Westerns War Sci-fi Disney 40's & 50's John Wayne ______________ ______________ ______________ ______________ Instruments Piano Organ ______________ ______________ ______________ Other

Crossword Jigsaw Word search Word scramble

Travel Genealogy Dancing Mending Collecting: Clothing ______________ _____________ Automotive ______________ Construction

Activity Participation Summary Key: Date_______ Daily = D Weekly = W Monthly = M Activity · · · · · · · · · · · · · · · · · · · · · Coffee club Music club Price is right Saturday cartoons Bingo Fancy nails Popcorn Movies Social Music program Cooking club Resident Council Yahtzee Card games Trivia Hangman Proverbs Derby day Mystery auction Bible Quiz Communion Srvc. Attend ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ · · · · · · · · · · · · · · · · · · · · Activity Bible study Church--Sun. Church--Thr. Mass Church specials Men's breakfast Holiday specials Birthday party Newsletter prep Special meals Order out lunch Lunch out Outing Van rides Cookie sales Fund raiser Kids Kare Resident Shopping Smoking Beauty shop Attend _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ · · · · · · · · Activity 1:1 visits comforting passive friendly music TV Independent Attend _____ _____ _____ _____ _____ _____ _____ _____ _____

Care Plan Review

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

NOTES:

Information

Initial Activity Assessment sheet

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