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an@dementiaresourcecommunity.co.uk
About Us
Admiral Nurses
Admiral Nurses
Mariners and Seafarers
Admiral Nurse Service Referral Form
Memory Assessment
Memory Assessment Feedback
Feedback Form
Feedback
Admiral Nurse – Carer Feedback
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News
Activities Planner
Activities Planner
Step
1
of
14
7%
Activities of Daily Living Planner
For :
Name
Home Address
Street Address
Address Line 2
City
County
Postcode
GP Name
GP Address
Street Address
Address Line 2
City
County
Postcode
GP Phone Number
Next of Kin Name
Next of Kin Address
Street Address
Address Line 2
City
County
Postcode
Next of Kin Phone
Next of Kin Email
Other People who are Important to me Name 1
Other People who are Important to me Phone 1
Other People who are Important to me Address 1
Other People who are Important to me Name 2
Other People who are Important to me Phone 2
Other People who are Important to me Address 2
Other People who are Important to me Name 3
Other People who are Important to me Phone 3
Other People who are Important to me Address 3
Introductory Note:
This form prints as a booklet and it is intended to assist activity workers record information about the preferences that older people they work with have activities of daily living. This information can be as simplistic or complex as the person whose preferences are being written about. The only golden rule is that the information must accurately reflect how the person likes to live their life on an ordinary day. It is helpful to think of the planner as a method of helping other staff and activity workers who do not know the person quite so well. We hope this is a book of assistance in recording information that activity workers often know but have not written down. It may help other staff use activities of daily living therapeutically by giving them information on a person likes their day to be ordered. It may help staff see another side to an older person or see an area where they have common interests and opportunities for interaction. The sections of this booklet by no means represent each and every feature of activities of daily living that we engage in. it may give you some ideas about other activities and preferences not considered here in this booklet. Extra pages can always be added to help with this. Pages can also be added if there is too much information for a single page.
Good Luck!
Music preferences
Music dislikes
TV/Radio preferences
TV/Radio dislikes
Newspapers, books and magazines
Indoor interests
Outdoor interests
What makes a really good day/night out?
Religion
Place of worship
Contact details of place of worship
Important ceremonies
Preferred style of worship/service
Associated food preferrences
Favorite hymns and prayers
Requests in relation to death or dying
Preferred time for breakfast
:
Hours
Minutes
AM
PM
AM/PM
Preferred time for lunch
:
Hours
Minutes
AM
PM
AM/PM
Preferred time for evening meal
:
Hours
Minutes
AM
PM
AM/PM
Preferred place(s) for eating
Preference for eating alone or in company
Cultural/Religious preferences (Kosher, Halal etc)
Health preferences (Vegetarian, low-salt etc)
Prescribed preferences (Diabetic, Gluten-free etc)
Particular likes (Food and drink)
Particular dislikes
Preferences for bedtime snack
Eating aids (Plate, guards, assistance's required etc)
Preferred times and drinks (Tea in bed, Horlicks before bed etc)
Preferred method of drinking (mug, adapted cup, straw etc)
Tea - Milk? Sugar?
Coffee - Milk? Sugar?
Other hot drinks
Cold drink preferences
Cold drink dislikes
Alcohol preferences
Difficulties in relation to alcohol
Preferences for pub drinking
Preferred local pub
Particular dress preferences
Underwear preferences
Nightwear preferences
Shirt/ blouse size
Skirt/ trouser size
Shoe size
Colour preference
Colour dislike
Fabric preference
Fabric dislike
Fabric allergies
Style preferences
Preferred shop for buying clothes
Preferred shops for buying shoes
Preferred time for going to bed
:
Hours
Minutes
AM
PM
AM/PM
Preferred time for getting up
:
Hours
Minutes
AM
PM
AM/PM
Preferences for bedclothes
Preferences for pillows
Preferred lighting
Preferred heat/ ventilation
Particular bedtime routines
Particular waking/ getting up routines
Other significant preferences ( drink, clock, bed socks etc)
Preferred bath time
:
Hours
Minutes
AM
PM
AM/PM
Preferred frequency
Preferred method (bath, shower, etc)
Preferred assistance (male, female, etc)
Preferred style of assistance - brisk and functional, slower and relaxed, etc)
Brand of soap/ shower gel
Preferences for talc, bubbles, fragrances
Aromatherapy, candles, soft radio music?
Preferences for washing items (sponge, flannel, towels)
Particular likes
Particular dislikes
Particular anxieties in relation to bathing
Skin products required for (allergies, rashes etc)
Creams and lotions
Fragrances
Make-up
Teeth cleaning - method and products
Fingernails - methods and products
Toenails
Chiropodist
Hair products required for (allergies, rashes etc)
Hair washing
Preferred hair products
Preferred drying methods
Hairdressing
Preferred hairstyle
Preferred shaving method (dry/wet)
Time and frequency
Aftershave
Places that are important to me
Place
Reason
Address
Place
Reason
Address
Place
Reason
Address
Additional information/ continuation sheet
Sensory
Aromatherapy
Snoezelen
Relaxation
Massage (Hand)
Massage (Head & body)
Reflexology
Tai Chi
Manicure
Rummage (feely-Bags) Box
Ball games
Balloon games
Artistic
Dancing
Music and Dancing
Singing and sing-a-longs
Playing instruments
Story telling
Poetry
Painting
Drawing
Collage
Pottery (non-kiln)
Printing
Brass-rubbing
Theatre Visits
Cinema Outings
Concert Outings
Hobbies
Knitting
Dressmaking
Metalwork
Embroidery
Patchwork
Crochet
Soft-toy making
Macrame
Lace Making
Woodwork
Carving
Furniture restoration
Upholstery
Picture making
Model making
Tai Chi
Manicure
Rummage (feely-Bags) Box
Ball games
Balloon Games
Armchair gardening
Flower arranging
Dried flower crafts
Gardening ( flowers)
Gardening( fruit and veg)
Greeting cards
Stamp collecting
Talking books
Jewellery making
Beadwork
Jam making
Sweet and biscuit making
Wine making
Cake decorating
House plant care
Domestic
Shopping
Laundry
Housework
Brass-cleaning
Cooking
Baking
Jam making
Sweet and biscuit making
Wine making
Cake decorating
House plant care
Active
Bowls and skittles
Ring-board and target
Basketball
Darts
Armchair sports
Parachute games
Golf
Swimming
Keep fit
Walking
Exercise machines
Talking
Discussion
Current affairs
Reminiscence
Debate
Coffee morning
Residents group
Multi-lingual skills
Privacy
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