Initial Assessment Form

Activities Initial Assessment
Name_____________________________________ Date__________________
Room #________________ Diagnosis_________________________________

Marital Status ‹ Married ‹ Divorced ‹ Single (Never Married) __Other
Past Occupation(s) ____________________________________________________________________________________________

Religion ‹Practicing ‹Non-practicing ‹Enjoys all religions

Registered to vote? ‹Yes ‹No ‹Would like to vote here

Activities/Hobbies/Interests that this person likes to pursue as well as learn about. Please encourage him/her to attend these programs when announced

Hobbies

‹ Gardening
‹Pets __________________
‹ Family Events
‹ Holiday Celebrations
‹ Bird Watching
‹ Boating
‹ Camping
‹ Hunting
‹ Fishing
‹ Cooking
‹ Crafts
‹____________________
‹____________________
‹____________________

‹ Favorite Game
_____________________

‹ Casino Games
‹ Crossword Puzzles
‹ Word Searches
‹ Reading
‹ Travel
‹ Dancing
‹ Movies
‹ Computers
‹ Cards

Spiritual Needs

‹ Services (attends regularly)
‹ Bible Study
‹ Meditation
‹ Temple
‹ Protestant Services
‹ Catholic Mass and Traditions
‹ Priest/Minister to visit 1-1
‹________________________
‹________________________

Sports
‹ ___ Sports Fan
‹ Baseball
_______________________
‹ Football
________________________
‹ Basketball
________________________
‹ NASCAR
________________________

‹ Soccer
‹ Horseshoes
‹ Bocce Ball
‹ Walking
‹ Horse Racing
‹ Snow Sports
‹ Olympics

‹ Card Playing
‹ Poker
‹ Bridge
‹ Hearts
‹ Solitaire
‹ Spades
‹ Rummy
‹ ___________________
‹___________________

‹ Crafts
‹ Knitting
‹ Crocheting
‹ _________________
‹ Sewing
‹ Painting
‹ Ceramics
‹ Scrapbooking
‹ Woodworking
‹ Writing
‹ House Décor
‹ Rubber Stamping
‹ Model Making
‹ Puzzles
‹ Crafty Crafts

‹ Games
‹ Bingo
‹ Board Games
‹_____________________
‹ Casino Games
‹ ____________________

Activities that we have here that the resident would like to attend

‹ Socials
‹ Teas
‹ Men’s Groups
‹ Veterans Programs
‹ Parties
‹ Entertainment

‹ Educational
‹ Biography
‹ Current Events
‹ You be the Judge
‹ Back to School
‹ Science Programs
‹ ___________________
‹____________________

‹ Community
‹ Movies
‹ Resident Council
‹ Outings
‹ Service Projects
‹ Entertainment
‹____________________
‹ ____________________
‹_____________________

Spiritual
‹ Protestant Service
‹ Catholic Mass
‹ Bible Study
‹____________________
‹____________________
‹____________________

Intergenerational
‹ Elementary School/Highe School/University visits
‹ Reading Programs
‹ Home School

1-1 and Individual Activiites
Bedside and Small Group

‹ Reading/ Talking Books/
Newspaper/ Magazines
type___________________
‹ Crossword Puzzles
‹ Crafts
‹ Snack/Soup/
Refreshment Cart
‹ Wheeling/ Walking
‹ Current Events
‹ Family Events
‹ Tea Cart
‹ Trivia
‹ Card Playing
‹ Word Searches
‹ Helping Others
‹ Listen to Radio
‹ Visits with Staff/Volunteers
‹______________________
‹ TV Specific Programs
‹_______________________
‹_______________________
‹_______________________

‹ Decorates Own Room
‹ Goes out on own
‹ Family visits regularly
‹ ______________________
‹ _______________________

Preferred Activity Setting

‹ Own Room
‹ Day/Activity Room
‹ Inside Nursing Home/off Unit
‹ Outside Nursing Home
‹ Community Programs on own
‹ Family Events
‹ Needs Assistance from Staff to
get to programs (transport to and from)
‹ Read calendar to him/her
‹ Favorite Snack/Food __________________
‹ Favorite TV _________________________ ‹ Other Interests

John T

John T

John was admitted to your facility with Parkinson and the inability to speak. He can make his needs known by hand gestures. He has an estranged daughter who lives out of town and will not be able to come and visit. He is an ex-boxer and more than likely has Parkinson due to the boxing. He is able to push the wheelchair around on his own using his good arm and his foot. He also has had a CVA affecting his right side.

How do we go about learning about what John would like to do? How can we learn about what he enjoys doing and what he would like to do? How can we document our conversations with him?

Carrie

Carrie

Carrie will be celebrating her 100th Birthday next year. She owned a grocery store in the neighborhood. It was a gathering spot for all the neighbors. She was married twice and outlived both husbands. She enjoyed her church functions and was an elder in the Pentecostal church. She was also active on her political committee, for which she watched the polls every year. She has five children who all live close by and state that they will visit often. However, since admission they have only visited to bring in her belongings.

She was admitted on a ventilator along with a fractured right arm. She also has MRSA and VRE. She is in a private room, has been very demanding of nursing staff and is always on the call bell. Nursing has requested that Activities give her something to do.

What type of activities, that you currently have on the calendar would she be interested in? How can you adapt her situation to include activities of interest??? How do we go about getting her interested in her new living situation.

Ethel

Ethel

Miss Ethel is 84 years young, she is a member of a Bridge Club that plays every week. She also enjoyed shopping and baked. She was a career women who never married, she worked for a law office as the secretary for the founding members of the law firm. She also trained other secretaries. She has traveled around the world, has scrapbooks of pictures and journals of all her trips. She has a nephew who lives four states away and stays in touch via phone to the facility.

She has MS and has been an active member in her community support group. Due to the loss of control she is confined to a wheelchair.

Looking at your current activities calendar, where would she "fit in"?? What would you provide for her considering what your activities calendar looks like right now.

Sam

Resident Personality

Let's discuss "Sam" for a moment. Sam came to the nursing Home with an amputee, bad diabetes and COPD. He has some mild confusion and has lived at the VA for the last three months since the amputation. Sam was born in late 1929.

His social history includes an avid crossword puzzle fan, doing the daily puzzle in the daily paper. He puttered about his house, fixing things and doing all the "traditional" husband projects and tasks. He mowed the lawn, washed the cars, took the trash out, walked the dog and enjoyed a good barbecue with his family. He also enjoyed fishing and is a former Navy lieutenant. He enjoyed his job, but did not have a "best friend". He went to social events planned by his wife and enjoyed family gatherings. When he was younger he would stop and have a drink with co-workers on Friday evenings before returning home.

He has four children and a wife who visits twice a week for the day. So based on your current activities and what you have on your calendar, where would Sam fit in? Would he be going to a whole bunch of activities? Would he be coming to Bingo??? How about Men's Club????

What do you think? Post your comments here.......