Initial Activity Assessment sheet

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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.

Games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yahtzee _____ _____ Cards Bridge Canasta Gin Uno Pinochle Poker

  Assessment