EDGEWOOD NURSING PROGRAM
Senior History Profile

After completing the senior history profile with your client, document your visit using the following guidelines:

1.  Introduction:  Describe where and when you met.
2.  In paragraph form, document the findings from the senior profile.
3.  Reflections:  How did you feel re: the visit?  How did the client react to your questions?  Any emotions exhibited?  How did you react to this?
4.  Self-evaluation:  What did you do well:  What would you do differently next time?

Name______________________________  Address__________________________________

Phone____________________ Age (optional)______ Place of Birth______________________

Parents Names   __________________________ Place of Birth__________________________

                            __________________________ Place of Birth__________________________

Who were you named after?

How old was your mother when you were born?  Were you the youngest of her children?

During your childhood, did you ever go to the hospital?  Did you have stitches or broken bones?

What type of transportation did you have when you were 10 years of age?  Do you remember any long trips?

What were your favorite outdoor activities when you were 10 years of age?

What was your favorite childhood toy?

What pets did you have and what were their names?

Who was your best childhood friend?  What made him/her your best friend?

What kind of appliances did you have to cook with, wash clothes and light the house when you were 10 years of age?

Describe the kitchen in your childhood home?

What was your favorite thing in the whole house?  Do you still have it?

Do you still have contact with any of your childhood friends?

What is your fondest memory of the house you lived in as a child?

What was your most memorable holiday celebration?  Why?

Do you remember a special gift you received from someone?  What was it?

What traditions did your family have?  Did you have any ethnic celebrations?

Who was your favorite childhood teacher?  Why?  How did they influence you?

How did you get to school?  Walk, ride, school bus, etc.?

Did you ever play hooky?  Who with?  What did you do?

What school activities or sports did you participate in?

In high school, what was the most popular dance step?  What was a favorite song?

What was your favorite TV or radio show?

How old were you when you learned how to drive?  What kind of car did you drive?

What do you remember most about being a teenager?

Where were you when Pearl Harbor was attacked?  What were your thoughts?

How did the war impact you personally?

Were you married?  If so, how did you meet your spouse?

Tell me about your wedding day.

Do you have children?  Tell me about your children.

What fads do you remember best from your 20's?

Is there anything you have always wanted to do, but have not?

Who are the people that most influenced you?  Why?

What events during your lifetime have changed the world the most?

What is the most memorable event of your life?

What person do you most admire and respect?  Why?

Is there any place that you would like to visit if you could?  Why?

What period of your life was the most enjoyable to you?  Why?

What advice do you have for me?

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