Transcription of EduCare Pre-training Exercise
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EduCare Pre-training Exercise
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 _____ Military Experience _____ Education _____ Occupation & training _____ Former Places of Residences _____ Significant Experiences / Achievements _____ Travel Experiences _____ Mirabelle Management, LLC 2007 Page 2 of 2 FAMILY AND FRIENDS Name of Spouse (if applicable) _____ Brothers/Sisters _____ Children _____ Grandchildren _____ Significant Friendships _____ ACTIVITY & PERSONAL INTERESTS List a
“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 ...
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