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Interaction Survey Form Assignment

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Objective: Conduct a General survey on a person of your choice. The purpose of this interaction is observation only.

  1. Physical Appearance/Hygiene:
    1. General appearance:
  2. Gender
  3. Apparent age
  4. Ethnic group
  5. Appears overall healthy
  6. Well-groomed or disheveled (Note the general color of skin and hygiene)  
  • Body Structure and Movement (Observe general stature):
  1. Height appropriate for apparent age
  2. Appears well nourished
  3. Weight suitable for the height
  4. Position or posture (comfortable and relaxed)
  5. Obvious deformities
  6. Walks with ease
  7. Gait balanced and smooth
  8. Limitations to range of motion
  9. Involuntary movements
  10. Using assistive devices
  • Emotional/Mental Status and Behavior:
  1. Level of alertness
  2. Appear well rested or tired
  3. Converse appropriately
  4. Behavior appropriate for the situation
  5. Dress suitable for the weather
  • Document observations with detailed responses in a narrative format.  For example, if a client appears tired provide a description adequate for the reader to visualize the client, “Client is alert and appears tired, slumped in a chair with eyes half closed.” 
  • Describe two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
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