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7. Former Occupation H
8. Religous/Spiritual preferences H
9. Education/training H
B. Attendance and Particpation Summary
1. Describe the resident's attendance preferences and partipation level with activities (group, event, 1:1) H
She prefers to pursue her own independent activity.
2. Describe resident's favorite activities, special accomplishments, and/or new interests. H
She enjoys greeting and socializing with staff and peers,watching TV; Spanish channels and classic films, strolling around the facility, and special events.
Interaction patterns (check all that apply)
3a. Independent activity involvement E H
3b. Initiates Interactions E H
3c. Needs encouragement to engage H
3d. Non-responsive H
3f. Non-verbal H
4. Additional Comments: H
C. Cognition/Behavior
Cognition
1a. Alert E H
1b. Confused H
1c. Short term memory loss H
1d. Long term memory loss H
1e. Impaired decision making H
1f. Able to make needs known E H
2a. Ability to understand others 1. Always 2. Usually 3. Sometimes 4. Rarely H
2b. Makes self understood 1. Always 2. Usually 3. Sometimes 4. Rarely H
Mood & Behavior Concerns
3a. Does behavior significantly interfere with resident participation in activities 1. Yes 2. No H
3b. If yes on 3a explain H
D. Daily Preferences
1a. How important is it to you to choose what clothes to wear? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1b. How important is it to you to take care of your personal belongings or things? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1c. How important is it to you to have snacks available between meals? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1d. How important is it to you to choose your own bedtime? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1e. How important is it to you to have your family or a close friend involved in discussion about your care? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1f. How important is it to you to be able to use the phone in private? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1g. How important is it to you to have a place to lock your things to keep them safe? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1h. How important is it to you to have books, newspapers, and magazines to read? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1i. How important is it to you to listen to music you like? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1j. How important is it to you to be around animals such as pets? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1k. How important is it to you to keep up with the news? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1l. How important is it to you to do things with groups of people? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1m. How important is it to you to go outside to get fresh air when the weather is good? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1n. How important is it to you to participate in religious services or practices? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1o. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1p. How important is it to you to do your favorite activities? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
2. Additional information H
E. Additional Activities
Preferences (Write in specific interests & ability
1. Arts/Crafts/ Creating E H
1a. Comments H
2. Cards/Table games H
2a. Comments H
3. Computer/Internet H
3a. Comments H
4. Cooking E H
4a. Comments H
5. Discussions/Reminiscense E H
5a. Comments H
6. Excercise/Sports H
6a. Comments H
7. Gardening H
7a. Comments H
8. Shopping/Outings E H
8a. Comments H
9. Resident Council H
9a. Comments H
10. Travel E H
10a. Comments H
11. Voting/community Involvement H
11a. Comments H
12. Watching TV/Movies E H
12a. Comments H
13. Word games/Puzzles H
13a. Comments H
14. Volunteering/Helping H
14a. Comments H
15. Other H
15a. Comments H
F. Staff Assessment
Complete only if 3 or mor items from interview were not completed by resident or RP
1. H
a. Choosing clothes to wear MDS H
b. Caring for personal belongings MDS H
c. Receiving tub bath MDS H
d. Receiving shower MDS H
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7. Former Occupation H
8. Religous/Spiritual preferences H
9. Education/training H
B. Attendance and Particpation Summary
1. Describe the resident's attendance preferences and partipation level with activities (group, event, 1:1) H
She prefers to pursue her own independent activity.
2. Describe resident's favorite activities, special accomplishments, and/or new interests. H
She enjoys greeting and socializing with staff and peers,watching TV; Spanish channels and classic films, strolling around the facility, and special events.
Interaction patterns (check all that apply)
3a. Independent activity involvement E H
3b. Initiates Interactions E H
3c. Needs encouragement to engage H
3d. Non-responsive H
3f. Non-verbal H
4. Additional Comments: H
C. Cognition/Behavior
Cognition
1a. Alert E H
1b. Confused H
1c. Short term memory loss H
1d. Long term memory loss H
1e. Impaired decision making H
1f. Able to make needs known E H
2a. Ability to understand others 1. Always 2. Usually 3. Sometimes 4. Rarely H
2b. Makes self understood 1. Always 2. Usually 3. Sometimes 4. Rarely H
Mood & Behavior Concerns
3a. Does behavior significantly interfere with resident participation in activities 1. Yes 2. No H
3b. If yes on 3a explain H
D. Daily Preferences
1a. How important is it to you to choose what clothes to wear? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1b. How important is it to you to take care of your personal belongings or things? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1c. How important is it to you to have snacks available between meals? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1d. How important is it to you to choose your own bedtime? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1e. How important is it to you to have your family or a close friend involved in discussion about your care? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1f. How important is it to you to be able to use the phone in private? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1g. How important is it to you to have a place to lock your things to keep them safe? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1h. How important is it to you to have books, newspapers, and magazines to read? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1i. How important is it to you to listen to music you like? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1j. How important is it to you to be around animals such as pets? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1k. How important is it to you to keep up with the news? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1l. How important is it to you to do things with groups of people? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1m. How important is it to you to go outside to get fresh air when the weather is good? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1n. How important is it to you to participate in religious services or practices? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1o. How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
1p. How important is it to you to do your favorite activities? MDS H
1. Very important
2. Somewhat important
3. Not very important
4. Not important at all
5. Important, but can't do or no choice
9. No response or non-responsive
-. Not assessed
2. Additional information H
E. Additional Activities
Preferences (Write in specific interests & ability
1. Arts/Crafts/ Creating E H
1a. Comments H
2. Cards/Table games H
2a. Comments H
3. Computer/Internet H
3a. Comments H
4. Cooking E H
4a. Comments H
5. Discussions/Reminiscense E H
5a. Comments H
6. Excercise/Sports H
6a. Comments H
7. Gardening H
7a. Comments H
8. Shopping/Outings E H
8a. Comments H
9. Resident Council H
9a. Comments H
10. Travel E H
10a. Comments H
11. Voting/community Involvement H
11a. Comments H
12. Watching TV/Movies E H
12a. Comments H
13. Word games/Puzzles H
13a. Comments H
14. Volunteering/Helping H
14a. Comments H
15. Other H
15a. Comments H
F. Staff Assessment
Complete only if 3 or mor items from interview were not completed by resident or RP
1. H
a. Choosing clothes to wear MDS H
b. Caring for personal belongings MDS H
c. Receiving tub bath MDS H
d. Receiving shower MDS H
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