Transcription of Initial Activity Assessment sheet
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Example: tourism industry
Initial Activity Assessment sheet
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: _____ When last used: _____ games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yah
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 _____ _____ Television News Sports Soaps Games Movies Cartoons ...
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