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: ______ Ki

Easy listening Puzzles Crossword Jigsaw Word search Word scramble Just for Fun Parties Picnics Plays Music programs Household Cleaning Laundry Dish washing Cooking Baking Decorating _____ _____ Sports Baseball Basketball Football Bowling Fishing Hunting Hockey Horseshoes Ring toss Volleyball _____ _____

  Assessment, Activity, Initial, Listening, Initial activity assessment