Arletta's Adult Care Home, Inc.

 

 

 

                             

 

PERSONAL BELONGINGS INVENTORY 

 

RESIDENT NAME:

NAME OF RESIDENT'S GUARDIAN

DATE OF ADMISSION

 

CONTACT LENSES                                                                      YES    NO 

EYE GLASSES                                                                          YES    NO 

DENTURES                                                                                 YES    NO 

HEARING AID                                                                          YES    NO 

WATCH                                                                                      YES    NO 

MONEY/CHECKBOOK/CREDIT CARDS

JEWELRY

 

 

 

 

 

OTHER

CLOTHING LIST

NO.

ITEM

DESCRIPTION

NO.

ITEM

DESCRIPTION

 

Bathrobe

 

 

Slippers

 

 

Belt

 

 

Slips

 

 

Blouse

 

 

Socks

 

 

Brassiere

 

 

Stockings

 

 

Coat

 

 

Suit

 

 

Dress

 

 

Suspenders

 

 

Girdle

 

 

Sweater

 

 

Gloves

 

 

Undershirt

 

 

Handkerchief

 

 

Underpants

 

 

Hat

 

 

Underwear-long

 

 

House coat

 

 

Vests

 

 

Necktie

 

 

Other:

 

Nightgown

 

 

 

 

Pajamas

 

 

 

 

Pants

 

 

 

 

Shirts

 

 

 

 

Shoes

 

 

 

 

Skirts

 

 

 

 

 

 

 

 

MISCELLANEOUS

NO.

ITEM

DESCRIPTION

NO.

ITEM

DESCRIPTION

 

Brush

 

 

Television  (Ser. No.)

 

 

Cane or Crutches

 

 

Walker

 

 

Clock

 

 

Wheelchair  (Ser. No.)

 

 

Luggage

 

 

Other

 

 

Radio

 

 

 

 

               

STATEMENT: I have read and agree that this is accurate list of my belongings.

PROVIDER SIGNATURE

 

DATE

RESIDENT OR GUARDIAN SIGNATURE

DATE

 
Copyright 1995 Arletta's Adult Care Home, Inc.                                        
Last modified: August 06, 2016