FlowersActivities Evaluation


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Activities Evaluation

Date_________________________



Name____________________________________________

Nickname________________________________________

Age_____________________________________________

Birthdate________________________________________

Religion_________________________________________

Occupation______________________________________



Spouseís Name_____________________________

Spouseís Occupation________________________

Anniversary________________________________



Hometown__________________________________

City/State resident___________________________

Spent majority of time________________________

Hobbies________________________________________________________

Education_______________________________________________________

Military-Past clubs/volunteer affiliations___________________________________



Favorite Color____________________________

Favorite Foods_______________________________________________________________

Pets_______________________


Children____________________________________________

Age_________________________________________________

Occupation_____________________________________________________


Grandchildrenís Names and Ages-_________________________________________________

Great Grandchildrenís Names and Ages- ____________________________________________________

Sisters and Brothers and Ages- _________________________________________________________________




Special Memories How can we make this resident feel welcome and comfortable at our facility?

Describe a typical daily routine for this resident____________________________________________________________________________________


List some of the residentís likes and dislikes____________________________________________________________________________________


List any special needs or medical concerns____________________________________________________________________________________


Any special dietary needs?______________________________________________________________________________________


Please check the activities in which resident might be interested:

Puzzles____________
Movies_____________
Pets_______________
Outings____________
Parties____________
Games____________
Music____________
Gardening__________
Cooking____________
Crafts_____________
Exercise___________
Lifeskills_________
Reading/Poetry_________
Current Events_________


List some other interests not included above:______________________________________________________________________________________________
_____________________________________________________________________________________________


Comments___________________________________________________________________________________________
_____________________________________________________________________________________________



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