Transcription of Initial Activity Assessment sheet
1 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.
2 _____ games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yahtzee _____ _____ Cards Bridge Canasta Gin Uno Pinochle Poker Euchre Rummy Solitaire _____ Pets Dog Cat Fish Birds Crafts Ceramics Crocheting Doll making Glass blowing Hooking rugs Knitting Leather working Needlepoint Plastic craft Scrap booking Stained glass Woodworking Embroidery Quilting Exercise Aerobic Stretching Walking Jogging Swimming Gardening Flowers Vegetables Shrubs House plants Cactus _____ Outing Ballgames Fishing Museums Parks Zoos Shopping Van rides Lunches Music Classical Country Gospel Jazz Big band 30 s & 40 s 50 s & 60 s Rhythm Rock & roll Heavy metal Rap 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 _____ Television News Sports Soaps games Movies Cartoons Comedy Adventure Drama Old TV Wrestling Reality TV Cable TV MTV HGTV Food Channel CNN Computer games Internet Writing Poetry Letters Haiku Short stories Reading Autobiographies Fiction Historical Nonfiction Fiction
3 Religious Science fiction Westerns Mystery Newspaper Poetry Romance Magazines Bible Art Oil painting Sculpture Watercolors Drawing Chalks Poly clay Sewing Mending Clothing _____ Movies Comedy Drama Musical Westerns War Sci-fi Disney 40 s & 50 s John Wayne _____ Instruments Piano Organ _____ Other Travel Genealogy Dancing Collecting: _____ Automotive Construction Interest Survey Blue = past interests Yellow = current interests NOTES:_____ _____ May we invite family & friends to facility functions? YES NO Information provided by: Resident____ Other (name): _____ Relationship: _____ Date: _____ Assessor: _____ Notes: _____ _____ Initial Activity Assessment Admission Date: _____ Admitted From: _____Physician: _____ Allergies: _____ Diagnosis: _____ _____ Therapy: Physical_____ Occupational_____ Speech_____ Oxygen_____ Special treatments:____ _____ Personal Safeguards: Wander Guard_____ Personal Alarm_____ Posey Hugger_____ Bed Alarm_____ Low Bed_____ _____ Mode of Expression: Speech_____ Writing_____ Gestures/sounds_____ Communication board_ _____ Being Understood.
4 Understood Usually Sometimes Rarely/never _____ Diet: Regular_____ NCS_____ NAS_____ Mec. Soft_____ Pureed_____ Tube feed_____ NPO_____ Thickened liquids_____ Other: _____ _____ Vision: Adequate_____ Impaired_____ Moderately impaired__ Highly impaired_____ Severely impaired_____ Glasses_____ _____ Hearing: Adequate_____ Minimal difficulty____ Special situations_____ Highly impaired_____ Hearing aid_____ _____ Permission to: Open/read mail_____ Use beauty shop_____ Put name in newsletter_ Photograph_____ Go on facility outing___ Do shopping for Amb/mode transport: Independent_____ Wheels self_____ Help wheel_____ Cane_____ Walker_____ Wheelchair_____ Physical Assessment _____ Name.
5 _____MedRec#_____ X = Yes Hand dominance: R L Registered to vote:____ Marital Status: M W S D Ability to: Read_____ Write_____ Religious affiliation: __ _____ Therapy: Physical_____ Occupational_____ Speech_____ Oxygen_____ Special treatments:____ _____ Mode of Expression: Speech_____ Writing_____ Gestures/sounds_____ Communication board_ _____ Being Understood: Understood Usually Sometimes Rarely/never _____ Vision: Adequate_____ Moderately impaired__ Highly impaired_____ Severely impaired_____ Glasses_____ _____ _____ Hearing: Adequate_____ Minimal difficulty____ Special situations_____ Highly impaired_____ Hearing aid_____ _____ Diet: Regular_____ NCS_____ NAS_____ Mec.
6 Soft_____ Pureed_____ Tube feed_____ NPO_____ Thickened liquids_____ Other: _____ _____ Personal Safeguards: Wander Guard_____ Personal Alarm_____ Posey Hugger_____ Bed Alarm_____ Low Bed_____ _____ Permission to: Open/read mail_____ Use beauty shop_____ Put name in newsletter_ Photograph_____ Go on facility outing___ Do shopping for _____ Amb/mode transport: Independent_____ Wheels self_____ Help wheel_____ Cane_____ Walker_____ Wheelchair_____ _____ Annual Activity Assessment Resident:_____ Medical Record #: _____Date:_____ _____ games Bingo Checkers Chess Backgammon Dominoes Monopoly Scrabble Yahtzee _____ _____ Cards Bridge Canasta Gin Uno Pinochle Poker Euchre Rummy Solitaire _____ Pets Dog Cat Fish Birds Crafts Ceramics Crocheting Doll making Glass blowing Hooking rugs Knitting Leather working Needlepoint Plastic craft Scrap booking Stained glass Woodworking Embroidery Quilting Exercise Aerobic Stretching Walking Jogging Swimming Gardening Flowers Vegetables Shrubs House plants Cactus _____ Outing Ballgames Fishing Museums Parks Zoos Shopping Van rides Lunches Music Classical Country Gospel Jazz Big band 30 s &
7 40 s 50 s & 60 s Rhythm Rock & roll Heavy metal Rap 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 _____ Television News Sports Soaps games Movies Cartoons Comedy Adventure Drama Old TV Wrestling Reality TV Cable TV MTV HGTV Food Channel CNN Computer games Internet Writing Poetry Letters Haiku Short stories Reading Autobiographies Fiction Historical Nonfiction Fiction Religious Science fiction Westerns Mystery Newspaper Poetry Romance Magazines Bible Art Oil painting Sculpture Watercolors Drawing Chalks Poly clay Sewing Mending Clothing _____ Movies Comedy Drama Musical Westerns War Sci-fi Disney 40 s & 50 s John Wayne _____ Instruments Piano Organ _____ Other Travel Genealogy Dancing Collecting: _____ Automotive Construction Activity Attend Activity Attend Activity Attend Activity Participation Summary Key: Date_____ Daily = D Weekly = W Monthly = M Care Plan Review Date.
8 _____ _____ Annual Interest Survey Blue = past interests Yellow = current interests 1:1 visits comforting passive friendly music TV Independent Coffee club Music club Price is right Saturday cartoons Bingo Fancy nails Popcorn Movies Social Music program Cooking club Resident Council Yahtzee Card games Trivia Hangman Proverbs Derby day Mystery auction Bible Quiz Communion Srvc. _____ Bible study Church Sun. Church Thr. Mass Church specials Men s breakfast Holiday specials Birthday party Newsletter prep Special meals Order out lunch Lunch out Outing Van rides Cookie sales Fund raiser Kids Kare Resident Shop-ping Smoking Beauty shop _____ NOTES.
