Initial Activity Assessment sheet

← Back to document page

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.

Reading Autobiographies Fiction Historical Nonfiction Fiction Religious Science fiction Westerns Mystery Newspaper Poetry Romance Magazines Bible Art Oil painting Sculpture Watercolors Drawing Chalks Poly clay Sewing Mending Clothing _____ _____ Movies Comedy Drama Musical Westerns War Sci-fi Disney 40’s & 50’s John Wayne

  Assessment, Activity, Reading, Bible, Initial, Initial activity assessment