About Me Form

A Day in the Life Of:  As Told By:




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:




























Hygiene:





Meals:





School/Day Program:




Staff:





Housekeeping:






Medical




Medications:






 Yes No



 Yes No



Shopping:




Financial:




 Yes No


 Yes No

Social/Recreational:







Entertainment:







Exercise:






Family:





Emotional:














Miscellaneous: