Transcription of Initial Activity Assessment sheet
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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.
Activity Attend Activity Attend Activity Attend Activity Participation Summary Key: Date_____ Daily = D Weekly = W Monthly = M Care Plan Review Date: _____ ... Annual Interest Survey Blue = past interests Yellow = current interests • 1:1 visits • …
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