Name____________________________________________

Nickname________________________________________

Age_____________________________________________

Birthdate________________________________________

Religion_________________________________________

Occupation______________________________________

Spouse’s Name_____________________________

Spouse’s Occupation________________________

Anniversary________________________________

Hometown__________________________________

City/State resident___________________________

Spent majority of time________________________

Hobbies________________________________________________________

Education_______________________________________________________

Military-Past clubs/volunteer affiliations___________________________________

Favorite Color____________________________

Favorite Foods_______________________________________________________________

Pets_______________________


Children____________________________________________

Age_________________________________________________

Occupation_____________________________________________________


Grandchildren’s Names and Ages-_________________________________________________

Great Grandchildren’s Names and Ages- ____________________________________________________

Sisters and Brothers and Ages- _________________________________________________________________

Special Memories How can we make this resident feel welcome and comfortable at our facility?

Describe a typical daily routine for this resident____________________________________________________________________________________

List some of the resident’s likes and dislikes____________________________________________________________________________________

List any special needs or medical concerns____________________________________________________________________________________

Any special dietary needs?______________________________________________________________________________________

Please check the activities in which resident might be interested:

Puzzles____________
Movies_____________
Pets_______________
Outings____________
Parties____________
Games____________
Music____________
Gardening__________
Cooking____________
Crafts_____________
Exercise___________
Lifeskills_________
Reading/Poetry_________
Current Events_________

List some other interests not included above:______________________________________________________________________________________________
_____________________________________________________________________________________________

Comments___________________________________________________________________________________________
_____________________________________________________________________________________________