CMS-Aligned Activity Assessment Form | Fillable PDF for Activity Directors & Life Enrichment Coordinators

Stop piecing together outdated assessment forms.

This 8-page fillable activity assessment PDF was built from the ground up for activity directors, life enrichment coordinators, and recreation therapy professionals working across adult day programs, assisted living, memory care, and skilled nursing facilities. It aligns with CMS F679, F680, and MDS Section F (F0400/F0500) requirements — so you're not just checking boxes, you're building a defensible, person-centered care plan that surveyors actually want to see.

Whether you're completing an initial admission activity assessment, a quarterly reassessment, or documenting a significant change in condition, this form walks you through every domain that matters — from cognitive and functional status to sensory abilities, communication style, behavioral considerations, and psychosocial wellbeing. Everything an activity professional needs to develop individualized programming is captured in one clean, organized document.

What makes this different from other activity assessment forms?

Most assessment forms floating around facilities were written 15 years ago and haven't been updated since. They ask about hobbies and favorite colors but miss the functional, cognitive, and psychosocial data that CMS expects to see tied to your activity care plan. This form closes that gap.

✓ Section 1 — Client Demographics: Name, DOB, admit date, room/ID number, care setting checkboxes (Adult Day through SNF), payer source, diagnoses, and precautions

✓ Section 2 — Personal Background & Life History: Birthplace, hometown, family, military, religion, cultural preferences, education, occupation, preferred name — the life story details that drive person-centered activity programming

✓ Section 3 — Functional Status & Abilities: Cognitive level, dementia type, ability to follow directions, sensory status (vision/hearing), mobility, fall risk, transfers, endurance, upper extremity function, fine motor skills, swallowing, communication method, and behavioral considerations including sundowning, wandering, and exit-seeking

✓ Section 4 — MDS Section F Activity Preferences: All 14 activity preference items from the MDS 3.0 (F0400/F0500) — news, reading, music, animals, groups, religious activities, outdoors, staying up late, phone use, snacks, and more

✓ Section 5 — Interest Inventory: 100+ checkbox options across 12 categories — Games, Puzzles, Crafts, Creative Arts, Outings, Social/Entertainment, Household/Life Skills, Pets, TV/Movies, Sports/Exercise/Wellness, Reading, Sensory/Relaxation, and Technology

✓ Section 6 — Lifestyle, Routines & Wellbeing Domains: Pre-admission daily routine, plus the 7 CMS Wellbeing Domains (Security, Autonomy, Growth, Connectedness, Identity, Joy, Meaning) with write-in fields for each

✓ Section 7 — Resident Goals & Strengths: Client-stated goals, strengths to build on, barriers to participation, and adaptations needed

✓ Section 8 — Additional History: Hobbies, dislikes, special needs, life memories, life skills, music preferences, and open notes

✓ Section 9 — Care Plan Recommendations: Recommended activity level, participation type, frequency, specific activity recommendations, and non-pharmacological behavior management interventions

✓ Sections 10 & 11 — Reassessment Schedule & Signatures: Assessment type (initial, quarterly, annual, significant change), next reassessment date, signatures for client/rep, activity professional with credentials line, and IDT review

📱 💻 🖨️ USE IT ANYWHERE — TABLET, LAPTOP, OR PRINTED

This is a true fillable PDF — not a flat scan, not an image. Every field is interactive.

✅ On a tablet (iPad or Android): Open in the free Adobe Acrobat Reader app, tap into any field, check any box, save your progress, and email it to the care team — all without printing a single page

✅ On a laptop or desktop: Fill it out directly in your web browser (Chrome, Edge, Safari, Firefox) or in Adobe Acrobat Reader — no special software needed

✅ Printed: Print as many copies as you need for clipboard use at the nurses' station, in resident rooms, or at the front desk for new admissions

✅ Save, share, and reuse: Save completed assessments to resident files, email them to physicians before appointments, attach them to care conference documentation, or store them in your EHR

Perfect for shift handoffs, IDT meetings, family conferences, physician appointments, survey prep, and care plan updates.

🏢 LOGO-READY FOR YOUR COMMUNITY

Every page includes a logo placeholder in the header so your facility, company, or organization can brand it as their own. Simply insert your logo using Adobe Acrobat and every page carries your community's identity.

👥 WHO THIS IS FOR

✓ Activity Directors and Assistant Activity Directors ✓ Life Enrichment Coordinators and Managers ✓ Memory Care Program Directors ✓ Recreation Therapy Professionals (CTRS) ✓ Adult Day Program Coordinators and Directors ✓ Assisted Living Activity Staff ✓ Skilled Nursing Facility Activity Departments ✓ Dementia Care Consultants and Educators ✓ Activity Professional Students and New Hires (great for onboarding and training) ✓ Corporate teams standardizing assessment forms across multiple communities

⚠️ Important Note

This is an activity programming and care planning support tool. It is not a medical, diagnostic, or clinical instrument. It does not replace the MDS, physician evaluations, or clinical assessments performed by licensed healthcare professionals. Always follow your community's policies, state regulations, and scope of practice.




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