EduCare Pre-training Exercise

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Mirabelle Management, LLC 2007 Page 1 of 2 EduCare Pre-training Exercise Dementia Series: Activities of Daily Living Take a few moments and complete the following questionnaire. What is important in your life? (list a minimum of five) The social history is intended to gather information that will be useful in designing programs. You may choose to answer all or none of the following questions once completed, this document is yours to keep. Name__________________________________ Nickname ______________________ Birthday _________ (not year, just month/day) Primary Family Contact _____________________________ Relationship ____________________ Secondary Family Contact ___________________________ Relationship ____________________ Hospital Preference______________________________ ___ Physician_______________________ RELIGION Church__________________________________ ____ Clergy ____________________________ Church Services Clergy Visits Communion Hymn Sings Rosary Sacraments TV Program No Spiritual Interest LIFE EXPERIENCES Birthplace ___________________ Ethnic Background ___________________________________ Languages Spoken/Understood ________________________________________ ________

“Mirabelle Management, LLC © 2007” Page 1 of 2 EduCare Pre-training Exercise Dementia Series: Activities of Daily Living Take a few moments and complete the ...

  Training, Exercise, Educare, Educare pre training exercise