Activities Evaluation
If you would like to print it out in plain text, click HERE
Activities Evaluation
Date_________________________
Name____________________________________________
Nickname________________________________________
Age_____________________________________________
Birthdate________________________________________
Religion_________________________________________
Occupation______________________________________
Spouse’s Name_____________________________
Spouse’s 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_____________________________________________________
Grandchildren’s Names and Ages-_________________________________________________
Great Grandchildren’s Names and Ages- ____________________________________________________
Sisters and Brothers and Ages- _________________________________________________________________
Describe a typical daily routine for this resident____________________________________________________________________________________
List some of
the resident’s 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___________________________________________________________________________________________
_____________________________________________________________________________________________
Sent to me by Nurse Crackers
Hope our logo helps you find your way back to us.