Activity Assessment

Your Activity Assessment Should Contain the Following:

Name-

Date-

Health problems-

Nickname-

Age-

Religion-

Occupation-

Spouse’s Name and Occupation-

Anniversary-

Hometown-

City/State resident spent majority of time-

Hobbies-

Education-

Military-

Past clubs/organizations-

Favorite color-

Favorite foods-

Children-

Age of child-

Grandchildren’s names/ages-

Siblings-

Special memories-

How can we make this resident feel comfortable at our facility-

Describe a typical daily routine for this resident-

List dislikes-

Any special needs or concerns-

Any special dietary needs-

Circle activities that are of interests-

Puzzles

Church/Religon      Pets

Parties      Music

Senior center classes      T.V.   Other

Crafts      Outings

Lifeskills     Movies

Games      Cards

Reading      Exercise

Gardening         Cooking

Current events