Please help us get to know you better by answering the following questions. If you need help, it is okay to ask someone to ask someone to help you! If something doesn’t apply to you, just leave it blank.
Daily Schedule:
What time do you get up in the morning? 5am 6am 7am 8am 9am 10am Other
What time do you usually shower/take a bath? Morning Afternoon Evening Before bed Other
When do you eat breakfast? 5am 6am 7am 8am 9am 10am Other
What time are your medications? Morning Afternoon Evening Before bed Other
What time do you go to program/school/work? 5am 6am 7am 8am 9am 10am Other
When do you eat lunch? 11am 12pm 1pm 2pm Other
When do you usually run errands or go shopping? Daily in AM Daily in PM Weekly Monthly Bi-Monthly Other
What time do you return from program/school/work? 12pm 1pm 2pm 3pm 4pm 5pm Other
When do you usually do laundry/dishes/housework? Morning Afternoon Evening Before bed Other
When do you do your daily exercises? Morning Afternoon Evening Before bed Other
What time do you eat dinner? 4pm 5pm 6pm 7pm 8pm Other
When do you start your usual nightly routine? 6pm 7pm 8pm 9pm 10pm Other
When do you usually go to bed? 6pm 7pm 8pm 9pm 10pm 11pm Other
Hygiene:
How often do you prefer to bathe/shower? More than once per day Daily Every other day Other
What hygiene tasks do you need extra help with? Bathing Shaving Toileting Tooth brushing/Flossing Other
Meals:
What is your favorite food to eat and beverage to drink?
What is your most favorite meal or food item to make?
What is your least favorite meal or food item to make?
Do you need assistance from your staff with eating meals? All the time Sometimes Never
School/Day Program:
What was the school/program that you remember being the most fun for you and what made it so much fun?
Name a school/program experience that you didn’t like very much:
Staff:
Who is/was your favorite staff and what made him/her so wonderful for you?
What quality do you most dislike in a staff?
Some things I would like my staff to know about me:
Housekeeping:
Do you like to keep your home neat/tidy or do you require a lot of assistance keeping organized?
What household chores do you like to do yourself?
What household chores do you want/need help with?
Are there places or things in your home that are off limits to others?
Medical
Do you prefer a lot of support during appointments? All the time Sometimes Never
Who do you like to have with you at medical appointments?
Medications:
Have you needed staff guidance with filling pill boxes? All the time Sometimes Never
Do you go to the pharmacy to pick up medications or does someone do it for you? I go myself Someone helps me Other
How do you remember to take your medications each day?
Do you drink alcohol? Yes No
If so, how often
Do you smoke cigarettes? Yes No
If so, how many per day?
Shopping:
How often do you like to go shopping for groceries or other items? More than once a week Weekly Two times a month Monthly As Needed
What stores do you like to shop at?
Financial:
Can you manage your own money, or do you need help?
Have you ever had problems with over-spending? If so, tell us about it.
Do you like to save money? Yes No
Do you ever run out of money? Yes No
Social/Recreational:
What is your favorite activity to do on the weekends?
Who do you enjoy spending time with outside your home?
Who is your best friend?
What qualities do you seek in a friend?
Do you have any regular weekly activities that you participate in? (Things like: Church, Special Olympics, People First, etc.)
Entertainment:
What is your favorite TV show?
What is your favorite movie?
What kind of movie do you like to watch? Comedy Drama Animation Horror Other
What type of books do you enjoy reading?
What kind of music do you like listening to?
Exercise:
What kind of physical activity do you like to do?
How often do you exercise? More than once per day Daily Every other day Other
Do you have a favorite sport or physical activity?
Family:
Name a favorite childhood memory:
What made it such a fond memory for you?
Who are you closest to in your family and how often are you in touch?
Emotional:
Happiness: Think of something that makes you feel very happy.
What does being happy look like for you?
Sadness: What is something that makes you feel very sad?
What do you do when you feel sad?
What helps you when you feel sad?
Anger: Name something that makes you feel very angry:
What does being angry look like for you?
What helps you to calm down when you feel angry?
Fear: What is something that makes you feel very scared?
What helps you when you feel afraid?
Excitement: What is something that makes you feel excited?
What does being excited look like for you?
Miscellaneous:
What is your favorite color?
If you could take a trip anywhere in the whole world, where would you go?
What do you feel has been your biggest accomplishment of the past year?
What are your goals for the next year?
What is something that you would like Compass to know about you?
What is the number one thing you would like Compass to help you with?
Use this box for anything you want. You could write a poem or story. It's up to you!