Transcription of EduCare Pre-training Exercise
1 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)
2 _____ Brothers/Sisters _____ Children _____ Grandchildren _____ Significant Friendships _____ ACTIVITY & PERSONAL INTERESTS List any social, civic, professional or church organization attended: _____ _____ Productive Activities: Assisting w/ Meal Preparation Setting the Table Clearing the Table Cooking Washing Dishes Drying Dishes Baking Assisting w/ Laundry Folding Laundry Ironing Sewing Assisting w/ Housekeeping Vacuuming/Sweeping Bed Making Dusting Assisting w/ Outdoor Chores Light Shoveling Sweeping Outside Trash Planting Gardens Watering Weeding Assisting w/ Misc. Chores Appointment Escort Getting the Mail Groceries Leisure and Life Enriching Activities: Playing Games Gin Solitaire Rummy Cribbage Bridge 500 Bingo Trivia Dominoes Casinos Puzzles Poker TV Game Shows _____ Horseshoes Bowling Ring Toss Frisbee Music Activities Piano Singing Radio Plays Instrument _____ Big Band Classical Country Gospel Polka Soul Religious Waltz Rock Talk Radio Woodworking Crafts Painting Ceramics Knitting Crocheting Needlepoint Macram Embroidery Television Reading Dancing Movies Out for Coffee or Lunch Birds Manicures Massage Outdoor Activities Walking Fishing Hunting Boating Golfing Enjoys Sports Baseball Football Basketball Hockey Auto Racing Other Activities or Interests.
