Name________________________________Prefes to be
called_________________________Admit date________
Diagnosis/Medical
History__________________________________________________________________________
Age______Birth
date______________Birthplace________________________________Heritage________________
Education_______________________Occupation_________________________________Religion_______________
Marital Status____________________ Contact
person____________________________Telephone_____________
| CREATIVE
|
READING
|
INTELLECTUAL
|
COMMUNITY
|
| Crafts________________________
|
Books________________________
|
Discussions___________________
|
Voting_______________________
|
| Knitting______________________
|
Large
print___________________
|
Current
Events________________
|
Politics_______________________
|
| Crocheting____________________
|
Talking
books_________________
|
Classes_______________________
|
Leadership____________________
|
| Needlework___________________
|
Magazines____________________
|
Crosswords___________________
|
Club/lodge____________________
|
| Sewing_______________________
|
Newspaper___________________
|
Word
games___________________
|
Veterans______________________
|
| Rugmaking___________________
|
_____________________________
|
Puzzles_______________________
|
Senior
center_________________
|
| Ceramics_____________________
|
|
Lectures______________________
|
Shopping_____________________
|
| Painting______________________
|
PERFORMANCE
|
Mathematics__________________
|
_____________________________
|
| Drawing______________________
|
Drama_______________________
|
Science______________________
|
|
| Lettering_____________________
|
Speech_______________________
|
_____________________________
|
OUTDOORS
|
| Models______________________
|
Storytelling___________________
|
|
Fishing_______________________
|
| Leather______________________
|
Puppets______________________
|
CULTURAL
|
Hunting______________________
|
| Weaving_____________________
|
Band________________________
|
Museums_____________________
|
Birdwatching__________________
|
| Photography__________________
|
Choir________________________
|
Theater_______________________
|
Nature
study__________________
|
| ____________________________
|
Joke-telling___________________
|
Fine
arts______________________
|
Car
rides_____________________
|
| ____________________________
|
Reading
aloud_________________
|
Ethnic
activities________________
|
Sunning______________________
|
|
|
_____________________________
|
Genealogy____________________
|
_____________________________
|
| MANUAL
ARTS
|
|
_____________________________
|
|
| Woodworking_________________
|
GAMES
|
|
PHYSICAL
|
| Metal
craft____________________
|
Cards________________________
|
RELIGIOUS
|
Exercising____________________
|
| Mechanical___________________
|
Chess/checkers________________
|
Bible
study____________________
|
Swimming____________________
|
| Refinishing___________________
|
Table
games__________________
|
Worship______________________
|
Dancing______________________
|
| Electronics____________________
|
Bingo________________________
|
Communion___________________
|
Walking______________________
|
| _____________________________
|
Pool_________________________
|
Pastoral
visits__________________
|
Bowling______________________
|
|
|
Lawn
games___________________
|
Fellowship____________________
|
Sports________________________
|
| MUSICAL
|
Floor
games___________________
|
_____________________________
|
_____________________________
|
| Singing______________________
|
|
|
|
| Instrument____________________
|
SOCIAL
|
VOLUNTEER
|
GARDENING
|
| Concerts______________________
|
Small
groups__________________
|
Visitation_____________________
|
Vegetables____________________
|
| Radio________________________
|
Large
groups__________________
|
Clerical______________________
|
Flowers______________________
|
| Records______________________
|
Conversation__________________
|
Domestic_____________________
|
Houseplants___________________
|
| Tapes________________________
|
Happy
hour___________________
|
Grandparenting________________
|
Flower
arranging______________
|
| _____________________________
|
Smoking_____________________
|
Teaching_____________________
|
Yardwork_____________________
|
|
|
Parties_______________________
|
Decorating____________________
|
|
| SPECTATOR
|
Reminiscing___________________
|
Hosting______________________
|
OTHER
|
| Sports________________________
|
Socials_______________________
|
Selling________________________
|
Pets_________________________
|
| Movies_______________________
|
Telephoning___________________
|
Newsletter____________________
|
Collections____________________
|
| TV__________________________
|
_____________________________
|
Planning
activities_____________
|
Contests______________________
|
| Travelogues___________________
|
|
_____________________________
|
Computers____________________
|
| Circus_______________________
|
GROOMING
|
|
Scrapbooks___________________
|
| _____________________________
|
Hair
set______________________
|
FOOD
|
Photo
albums_________________
|
|
|
Make
up_____________________
|
Preparation___________________
|
_____________________________
|
| EXPRESSIVE
|
Barber_______________________
|
Eating_______________________
|
_____________________________
|
| Writing______________________
|
Manicures____________________
|
Dining
out____________________
|
_____________________________
|
| Poetry_______________________
|
Fashions______________________
|
Learning
diet__________________
|
_____________________________
|
| Correspondence______________
|
_____________________________
|
_____________________________
|
_____________________________
|
| Sign
language_________________
|
_____________________________
|
_____________________________
|
_____________________________
|
| Foreign
language______________
|
_____________________________
|
_____________________________
|
_____________________________
|
Arletta's
Adult Care Home, Inc.