Social History Questionnaire

Transcription

1 (To be completed by assessor or family member if appropriate) Directions: To the best of your ability, ask the client as many questions as you can and record the information in the space provided. Upon completion, return this form to the Main office. Next, complete the Social History Question Client Summary form and provide to the caregiver(s) for recommended meaningful activities to be performed in the home. Client name: Date of completion: Person completing the form: GENERAL INFORMATION QUESTIONS 1. Where did the client grow up? 2. What is the client s nationality? 3. Does the client speak a second language? Y / N If yes, list language: 4. What was the client s occupation/place of work? 5. What was the client s highest level of education? High school College (undergraduate) College (graduate school) Post graduate studies Trade or technical school If schooling exceeded high school, list what the client studied: 6. Are there any observances or religious requirements that we need to be aware of? 7. What milestones has the client experienced? Answer below. Marriage. Year: Birth of children. How many: Birth of grandchildren. How many: Birth of great-grandchildren. How many: Graduation from school/college. Year: Retirement. Year: Awards. List: 8. Is the client a veteran? Y / N Air Force Army Marines Navy If yes, list any memorable service events: and provides all clients with quality services without discrimination. 1

2 MUSIC QUESTIONS 9. Does the client enjoy music? Y / N If no, skip this section. 10. What method does the client have available to play music? Check all that apply. Boom box Radio ipod 11. Did the client play a musical instrument? Y / N If yes: List type(s): Does the client still play the musical instrument? Y / N 12. Does the client like to sing? Y / N If yes, List favorite songs to sing along to (hymns, Christmas carols, etc.): List favorite type of music to sing: 13. What are the client s favorite type of music? Check all that apply. Classical Show tunes Jazz Inspirational or religious Easy listening Opera Rock Country 14. Who is the client s favorite band or solo artist? 15. What is the client s favorite song? INTEREST QUESTIONS 16. Did the client belong to any clubs or organizations? Y / N Rotary VFW Lion s Club If yes: Does the client still maintain an active membership with their club? Y /N Does the client participate in activities with the club? Y / N If yes, indicate active involvement (dates, events, etc.): 17. Who are the client s favorite performers or entertainers (dancer, actor, comedian, etc.)?: and provides all clients with quality services without discrimination. 2

3 18. What is the client s favorite movie(s): 19. What is the client s current favorite TV show: 20. What is the client s previous favorite TV show: 21. Does the client have a favorite radio program? Y / N If yes, list the favorite radio program(s): 22. Did the client ever play a sport? Y / N. If yes, list which sport(s): 23. What is the client s favorite sport to watch? 24. Does the client like to garden? Y / N If yes, what type (garden, flower, herb, etc.): 25. Does the client enjoy nature activities? Y / N. Bird watching Nature walks 26. What type of games and other quite activities does the client enjoy doing? Check all that apply. Board games. If selected, list type: Crossword puzzles. If selected, list type (newspaper, etc.): Jigsaw puzzles. If selected, list type (advanced, easy, etc.): Cards. If selected, list type: Are these activities available in the home to play? Y / N 27. Does the client like to play cards? Y / N If yes, list the card game(s) that the client likes to play: If yes, are a complete set of cards available in the home? Y / N 28. Does the client like to participate in art activities or have an interest to do so? Y / N Painting Drawing Ceramics Knitting Sewing 29. Does the client enjoy trivia questions? Y / N 30. Does the client like to read? Y / N If yes, what does the client like to read (newspaper, historical fiction, war time, science fiction, etc): 31. Does the client like to build model toys? Y / N If yes, list type: and provides all clients with quality services without discrimination. 3

4 COOKING QUESTIONS 32. Does the client like to cook? Y / N If yes, what are the client s capabilities to cook? Check all that apply. Full assistance Partial assistance No assistance 33. What is the client s favorite type of food? 34. What is the client s favorite meal? 35. Are family cookbooks or recipes available to reference for meal preparation? Y / N If yes, indicate the location of these items: Cookbook: Recipes: COMMUNITY QUESTIONS 36. What community events did the client like to attend (theater, concerts, dance halls, etc.): 37. What community events does the client like to attend? Check all that apply. Broadway shows Sporting events Concerts 38. What community places does the client like to visit? Check all that apply. Art museums Library Senior center Church OTHER 39. Please list any other hobbies or interests that we should be aware of: and provides all clients with quality services without discrimination. 4

5 FOR OFFICE USE ONLY Directions: Upon completion of the SHQ, indicate below the items needed to develop a personalized meaningful activity bag. Items available in the home: Items that need to be purchased: Who will debrief caregiver(s) on interests specific to the client: Date in which debrief took place: Will the meaningful activity bag be delivered to clients home or will caregiver pick up bag? Circle one: Delivered Caregiver Pick up Was the SHQ Client Summary Sheet completed? Y / N Is the SHQ Summary Sheet available in the client s home? Y / N and provides all clients with quality services without discrimination. 5