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EVERMORE SPECIALTY CARE

Providing Unique Recreation for Seniors and the Aging Population

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Engagement Kits
Recreation Sessions
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Engagement Kit / Recreation Sessions

If you are interested in our services, fill out the form below and someone will contact you shortly

Recreation Assessment Form

First name

Last name

Birthday

Year

Month

Day

Phone

Address

Person completing form + email and phone

Date Assessment Completed

Year

Month

Day

Preferred Activities

Arts & Crafts

Music

Games

Reading

Outdoor Activities

Social Activities

Spiritual

Health & Wellness

Comments:

Functional Abilities

Independent Mobility

Assisted Mobility-Walker, cane

Wheelchair

Good Fine Motor Skills

Limited Fine Motor Skills

Verbal Communication

Non-Verbal Communication

Requires Cueing

Comments:

Cognitive Function Level

Intact

Mild Cognitive Impairment

Moderate Cognitive Impairment

Severe Cognitive Impairment

Dementia

Specific Dementia Diagnosis:

Comments:

Emotional Regulation Considerations

Sundowning

Agitation

Wandering

Exit Seeking

Anxiety

Aggression

Withdrawal/Isolation

Hullucinations/Delusions

Sleep Disturbance

What would you like to gain from our services?

Reach out to us here at Evermore for more information about our programs and services.

Telephone: (416)844-6730

Email: evermoreseniorcare@zoho.com

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