Activity Survey
L’Chaim Adult Day Program
Admission Assessment
Client Activity Survey
Name:_____________________
Diagnosis:__________________
Vision: Glasses o Reading o Distance o N/A
Hearing: Hearing Aide o Yes o No
Orientation: o Person o Place o Time
Marital Status: o Married o Single o Widow o Divorced
Religion:_____________________________ Birthplace:_________________________
Previous Occupation:___________________ Education:_________________________
Languages:___________________________
# of years in Canada:_________________
Countries lived
in:______________________________________________
Children:_______________________________________________________________
Grandchildren:___________________________________________________________
|
Physical Activity: o Dancing o Floor bowling o Chair exercises o Shuffleboard o Darts o Walking o Horseshoes o Chair hockey o Day trips o Golf |
Other Interests: o Gardening o Pets o Cooking/baking o Handcrafts o Singalongs o Reading/Storytelling o Musical instruments o Movies/Documentation o Music o Sports o Current events | |
|
Social Interests: o Cards o Scrabble o Table games o Bingo o Parties o Puzzles oDiscussions |
Any additional comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ | |
Completed by:___________________________ Date:_____________