A. BACKGROUND / FACTUAL INFORMATION
Resident : ______M. R. # ______Room # ______
Name Preference: ______Sex: M F Date of Birth: ______
Marital Status: M D W S Spouse’s Name: ______Place of Birth: ______
Names of Children: ______
# of Grandchildren: ______# of Great-Grandchildren: ______POA & Phone #: ______
Veteran: Yes – Branch ______ No Religious Affiliation: ______
Education Level: ______Read: Regular Print Large Print Language(s): ______
Former Occupation(s): ______
Organizations and Clubs: ______
Lifelong Wish: ______Registered Voter: Yes No
Special Skills/Talents: ______Use Photograph for Facility Use? Yes No
B. ADMISSION INFORMATION
Date of Admission: ______/______/______Review Dates: ______/______/______/______/______/______/______
Living Arrangement Prior to Admission: ______
Diagnosis: ______
______
Physician: ______Anticipated Length of Stay: Long-term Short-term
Orders/Permissions: May Join Activities Yes No Attend Outings Yes No May Have Alcohol Yes No
C. PHYSICAL ASSESSMENT AND ORDERS
Therapy:
Physical ______
Occupational ______
Speech ______
Oxygen ______
Other ______/ Handedness:
Right ______
Left ______
Ambidextrous ______/ Mode of Expression:
Speech ______
Writing ______
Vocalizations ______
Communication Board ______/ Vision:
Adequate ______
Impaired ______
Mildly ______
Severely ______
Glasses ______/ Diet:
Regular ______
NAS/Cardiac______
LCS/Diabetic______
Renal ______
Other: ______
Mech. Soft ______
Puree ______
Thickened Liquids:
Nectar ______
Honey ______
Pudding ______
Personal Safeguards:
Wander Guard ______
W/C Alarm ______
Motion Detector _____
Fall Risk ______
Other ______/ Transportation:
Independent ______
Walker/Cane ______
W/C ______
Self-Propel ______
Transfer ______/ Understands Others:
Yes No
Makes Needs Known:
Yes No
Alert & Oriented:
Person Place Time / Hearing:
Adequate ______
In Quiet Settings _____
Impaired ______
Hearing Aides:
Right Left
Activity Staff: ______Date: _____/_____/_____
If resident is permanently discharged, but is readmitted at some future date,
Complete the following and highlight the discontinued information in the respective section(s) above.
Updated by: ______Date: _____/_____/_____
Updated by: ______Date: _____/_____/_____
D. ACTIVITY INTERESTS AND FAVORITES
Favorites:
Book: TV Show: Movie:
Season: Time of Day: Holiday:
Color: Flower: Animal:
Game: Place: Singer:
Food: Beverage: Restaurant:
(1) Very Important (2) Somewhat Important (3) Not Very Important (4) Not Important at All
a. How important is it to you to have books, newspapers, and magazines available? (1) (2) (3) (4)
What equipment/supplies are needed: lighting, audio books, subscriptions, large print, magnifiers, being read to, etc?
Types of Reading Material
4
Fiction
Non-fiction
Religious/Bible
Historical
Biographies
Humor/Comic Books
Western
Best Sellers
Mystery
Science Fiction
Picture Books
Poetry
Classics
Horror
Drama/Stage Plays
Romance
Self-Help
Motivational
Newspapers
Educational Books
4
Others:
Magazine Titles:
b. How important is it to you to listen to music you like? (1) (2) (3) (4)
Types of Music Enjoyed
4
Big Band/Swing
Bluegrass
Children’s/Lullabies
Classical
Country
Crooners
Cultural
Dance
Folk
Gospel/Christian
Heavy Metal
Hip Hop
Holiday
Jazz
New Age
Opera
Piano
Pop/Top 40
Rap
Rhythm & Blues
Rock (Classic Rock)
Rock (Oldies Rock)
Techno
Others:
4
Era Music: Pre-1900s – 20s 30s 40s 50s 60s 70s 80s 90s 2000s
Favorite Songs:
Favorite Artists:
How listen to music? Tape CD MP3/Ipod Records
Belonged to: Choir Band Orchestra
Instruments Played:
c. How important is it to you to be around animals such as pets? (1) (2) (3) (4)
Any Animal Allergies: Yes No - if yes, list:
Fear of Animals: Yes No - if yes, list:
4
Favorite Animals:
Pets Owned:
Watch Animal Channel? Yes No
Read Animal Books? Yes No
4
d. How important is it to you to keep up with the news? (1) (2) (3) (4)
How Do You Follow The News?
4
Newspaper
Television
Magazines
Radio
Internet
4
e. How important is it to you to do your favorite activities? (1) (2) (3) (4)
f. How important is it to you to do things with groups of people? (1) (2) (3) (4)
g. How important is it to you to do things away from the nursing home? (1) (2) (3) (4)
4
Shopping
Out to Eat
Out with Family
Museums
Historical Sites
Library
Zoo
Sporting Events
Movie Theater
Parks
Drives
Concerts/Plays
4
Others:
Community Service Interests (Volunteer Groups)
Community Group Interests (Support Groups, Clubs, Veterans, etc.)
h. How important is it to you to go outside to get fresh air when the weather is good? (1) (2) (3) (4)
i. How important is it to you to participate in religious services or practices? (1) (2) (3) (4)
Favorite Prayers:
Favorite Hymns:
Traditions:
Which Services Do You Want To Attend?
Sunday Worship Catholic Mass Rosary Prayer & Praise
Lutheran Service Lenten Services Bible Study Other:
Other Lifelong & Potential Interests:
Card Games
4
Poker
Blackjack
Gin Rummy
Bridge
Skip Bo
Penny Ante
Cribbage
Go Fish
Rummy
Canasta
Golf
War
Kings Corner
Sheepshead
Old Maid
Slap Jack
Hearts
Euchre
Uno
Pinochle
4
Others:
4
Table Games
4
Chess
Trouble
Backgammon
Checkers
Scrabble
Clue
Sequence
Yahtzee
Dominoes
Monopoly
Sorry
Bingo
4
Others:
Intellectual Activities
4
Crossword Puzzles
Jigsaw Puzzles
Book Club
Word Games
Creative Writing/Poetry
Reading
Spelling Games
Discussion Groups
Trivia Games
Debate
Journaling
Correspondence
4
Others:
Athletics/Sports
4
Exercise
Jazzercise
Walking/Running
Yoga
Tai Chi
Basketball
Racquetball
Pool
Football
Croquet/Bocce Ball
Golf
Baseball/Softball
Ping Pong
Fishing
Bowling
Volleyball
Tennis
Badminton
Hunting
Camping
Horseback Riding
Horseshoes
Swimming
4
Dancing: Clogging Line Dancing Swing Square Dancing Ballroom/Latin 50s/60s
Others:
Daily Life Activities
4
Cooking
Baking
Canning
Laundry/Folding
Mail Delivery
Yard Work
Setting Table
Reading Newspaper
Gardening
Cleaning
Maintenance/Repairs
Polish Silverware
4
Others:
Creative Arts
4
Sewing
Needlepoint
Knitting
Crocheting
Drawing
Painting
Scrapbooking
Beading/Jewelry
Pottery/Ceramics
Woodworking
Quilting
Photography
4
Others:
Movies
4
Westerns
Comedy
New Releases
Action
Science Fiction
Seasonal
Classics
Horror
Musicals
Drama
Romance
War
4
Others:
Traveling
Places traveled to:
Places wanted to travel to:
E. DAILY PREFERENCES
(1) Very Important (2) Somewhat Important (3) Not Very Important (4) Not Important at All
a. How important is it to you to choose what clothes to wear? (1) (2) (3) (4)
b. How important is it to you to take care of your personal belongings or things? (1) (2) (3) (4)
c. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
(1) (2) (3) (4) Which to you prefer?
d. How important is it to you to have snacks available between meals? (1) (2) (3) (4)
e. How important is it to you to choose your own bedtime? (1) (2) (3) (4)
Time awake in the morning? Time go to bed at night? Nap?
f. How important is to you to have your family or a close friend involved in discussions about your care?
(1) (2) (3) (4)
g. How important is it to you to be able to use the phone in private? (1) (2) (3) (4)
h. How important is it to you to have a place to lock your things to keep them safe? (1) (2) (3) (4)
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