General Application Form Page 4
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6EMPLOYMENT HISTORY
Occupation ______________________ Workplace ____________________________
Past Occupations
___________________________________________________________________________
Were you employed at the time of your stroke/accident/illness?
Yes
No
Are you on a leave of absence? Yes
No
How long? _______
Are you retired?
Yes
No
How long? _______
Are you retired due to your stroke/accident/illness?
Yes
No
EDUCATIONAL HISTORY
What was highest grade level you completed in school?______________________
Did you attend university/college?
Yes
No
School Name
Degree _________________________
Is English your first language?
Yes
No
Were you ever fluent in any other language(s)?
Yes
No
If yes, what languages? ___________________________________________________
LEISURE TIME
Do you consider yourself an active person (you enjoy conversation and
participating in activities with others)?
Yes
No
What do you do in an average day?
_____________________________________________________________________________
_____________________________________________________________________________
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Parent category: Business