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
|
|
Arletta's
Adult Care Home, Inc.