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: ________________________________________ ________________________________________ ___ ________________________________________ _____________

Yahtzee _____ _____ Cards Bridge Canasta Gin Uno Pinochle Poker Euchre Rummy Solitaire _____ _____ Pets Dog Cat Fish Birds Crafts Ceramics Crocheting Doll making Glass blowing Hooking rugs Knitting Leather working Needlepoint Plastic craft Scrap booking Stained glass Woodworking Embroidery Quilting Exercise

  Assessment, Activity, Initial, Yahtzee, Initial activity assessment