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