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Admissions Report
Transcriptions
Type of Assessment
Assessment Type *
Admission
ReAdmission
Diagnoses
Diagnoses *
Resident Background / Factual Information
Preferred Name
Former Occupation
Religion
Registered Voter
Yes
No
Veteran
Yes
No
Education
Children
Yes
No
If Yes, How many Children
Grandchildren
Yes
No
If Yes, How many Grandchildren
Communication & Cognition
Oriented to Person *
Yes
No
Oriented to Place *
Yes
No
Oriented to Time *
Yes
No
Short Term Memory *
Good
Adequate
Poor
Long Term Memory *
Good
Adequate
Poor
Decision Making Skills *
Good
Adequate
Poor
Hearing Aid or other appliance used
Yes
No
Making Self Understood *
Understood
Usually Understood (Difficulty communicating some words or finishing thoughts but is able if prompted or given time)
Sometimes Understood (ability is limited to making concrete requests)
Rarely / Never Understood
Ability to Understand Others *
Understands (clear comprehension)
Usually Understands (misses some part / intent of message but comprehends most of the conversation)
Sometimes Understands (responds adequately to simple, direct communication only)
Rarely / Never Understands
Hearing *
Adequate (no difficulty in normal conversation, social interaction, listening to TV)
Minimal Difficulty (difficulty in some environments e.g. when person speaks softly or setting is noisy)
Moderate Difficulty (speaker has to increase volume and speak distinctly)
Highly Impaired (absence of useful hearing)
Vision *
Adequate (sees fine detail, such as regular print in newspapers/books)
Impaired (sees Large print, but not regular print in newspapers/books)
Moderately Impaired (limited vision; not able to see newspaper headlines but can identify objects)
Highly Impaired (object identification in question, but eyes appear to follow objects)
Severely Impaired (no vision or sees only light, colors of shapes; eyes do not appear to follow objects)
Corrective Lenses (Contacts, Glasses, or Magnifying Glass)
Yes
No
Activity Interests
Games: Cards - Word - Trivia - Bingo
Past
Current
Not Interested
Description of Interest
Puzzles
Past
Current
Not Interested
Arts & Crafts, Woodwork, Ceramics
Past
Current
Not Interested
Description of Interest
Knitting, Crocheting
Past
Current
Not Interested
Drawing, Painting
Past
Current
Not Interested
Reading, Writing
Past
Current
Not Interested
Description of Spiritual Interests above
Visits with Clergy
Past
Current
Not Interested
Description
Trips, Outside the Facility
Past
Current
Not Interested
Shopping
Past
Current
Not Interested
Description
Walking, Wheeling Outdoors
Past
Current
Not Interested
Description
Reminiscing
Past
Current
Not Interested
Women's Group / Men's Group
Past
Current
Not Interested
Description of Group
Watching TV, Movies
Past
Current
Not Interested
Description
Description
Talking, Conversing
Past
Current
Not Interested
Helping Others, Volunteering
Past
Current
Not Interested
Parties, Social Events
Past
Current
Not Interested
Description
Hobbies
Past
Current
Not Interested
Description
Visits with Cat or Dog
Past
Current
Not Interested
Has a Pet at Home
Yes
No
Description
Current Events Group
Past
Current
Not Interested
Description
Smoking
Past
Current
Never Smoked
Description
Exercise Groups, Sports (including watching sports on TV)
Past
Current
Not Interested
Music, Singing (including listening to the radio)
Past
Current
Not Interested
Spiritual, Religious - with groups (include watching religious services on TV)
Past
Current
Not Interested
Gardening, Plants (include watching gardening shows/videos)
Past
Current
Not Interested
Other Interests
Assessed Needs
Signature *
Date *
Identified Needs/Focuses for Activity Intervention (explain below) *
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