Nursing Home Activity Participation Form
Nursing Home Activity Participation Form
Please fill out this form to let us know about your activity preferences.
Resident Information
Name
Date of Birth
Room Number
Emergency Contact Phone Number
Activity Preferences
Preferred Activities
Please select preferred activity types:
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Arts and Crafts
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Music Therapy
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Exercise and Fitness Classes
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Game Nights (Bingo, Cards, etc.)
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Social Events and Gatherings
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Reading or Story Time
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Spiritual/Religious Services
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Outdoor Activities
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Gardening
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Educational Classes
How often would you like to participate in activities?
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Daily
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Several times a week
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Weekly
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Occasionally
Are there any physical limitations we should consider for activity planning?
If yes, please specify
Consent
I (or my legal representative) consent to the participation in the selected nursing home activities.
Name:
Date:
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