Leisure and Lifestyle Assessment

First Name

Last Name

LIFE STORY

Please write a brief life story:

HAIRDRESSER (additional cost)

Would you like to visit the hairdresser that visits Mayfield Aged Care
Yes No

What services would you like performed?

How often?

Hearing / Speech / Vision

Do you have have dysphasia?
Yes No

Do you have hearing aids?
Yes No

What kind?
In the ear Over the ear

Are there any further issues with communication?

Do you wear glasses?
Yes No

Description of glasses

Brand:

Colour

Metal/Plastic?

PODIATRIST

Will you be visiting the podiatrist that visits Mayfield?
Yes No

Any special information the podiatrist needs to know?

CELEBRATIONS

Which celebrations would you like to participate in?
Christmas Easter Birthdays ANZAC Day Australia Day Melbourne Cup Mother's Day Father's Day Other

Please specify

BACKGROUND INFORMATION

Past Occupation?

Place of work

Level of Schooling

Further education?

War service?

Volunteer Work?

Organisations or clubs involved in?

Places lived prior to admission

Countries or places visited prior to admission

FAMILY & FRIEND DETAILS

Marital status?
Single Married Widowed Divorced Separated De facto Prefer not to say

Name of spouse?

Date and place of marriage?

Siblings:

Children:

Grandchildren:

Close friends/visitors:

Other information:

INTERESTS / FAVOURITES

Music?

Books?

Television shows?

Movies?

Sports?

Radio programs?

Favourite topics for discussion?

Favourite sayings?

Favourite pets?

Flower?

Colour?

Resident's attitude and opinios of leisure/socialising?

Characteristics?

Other past interests?

Other present interests?

Would the resident like to participate in any of the following activities?
Bus trips Football tipping Cards and board games Painting Housie Craft Newspaper discussion Concerts Attend religious services Gardening Lunch outings Men's group

Religious denomination?

Representative?

Regligious needs or customs?

Last Rites?
Yes No

Would the resident like to participate in the community visitors scheme?
Yes No

Any further information that will assist us in better care?

Representative Signature

Reset Signature

Representatives Name

Date signed

Leisure and Lifestyle Assessment

Leisure and Lifestyle Assessment Form

Where to Next...

Contact Us