Rehabilitation Center Daily Activity Check-in Form
Please complete this form to record daily activities and observations for each resident.
Resident Full Name
*
First Name
Last Name
Resident ID Number
*
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Session Time
*
Please Select
Morning
Afternoon
Evening
Activities Participated In
*
Physical Therapy
Occupational Therapy
Group Exercise
Arts & Crafts
Music Therapy
Social Activities
Other
Level of Engagement During Activities
*
Not Engaged
1
2
3
4
Highly Engaged
5
1 is Not Engaged, 5 is Highly Engaged
Mood Observed During Session
*
Calm
Happy
Anxious
Agitated
Tired
Other
Participation Assessment
Rows
Fully Participated
Partially Participated
Declined
Physical Therapy
1
2
3
Occupational Therapy
4
5
6
Group Exercise
7
8
9
Arts & Crafts
10
11
12
Music Therapy
13
14
15
Social Activities
16
17
18
Additional Notes or Observations
Staff Member Completing This Form
*
First Name
Last Name
Submit Check-in
Should be Empty: