Page 21 - From Good Sleep to Wellness
P. 21
Preferred Times for Meals
________ Morning ________ Afternoon ________ Evening
Naps ⬜AM ⬜
Recliner
⬜PM ⬜Bed
Beauty/Barber Shop Services
Daily Pleasures
Favorite Subject to talk about
Form #: Date Revised: Date Implemented: © 2005 Manhattan Retirement Foundation Inc.
Bedtime Rituals
Usual Bedtime: _____________ ⬜ Light On
⬜ Door Open Repositioning in bed: ⬜ PartialAssist
⬜ TotalAssist
⬜ Assistive Devise
Preferred Clothing:
Preferences and Needs:
Assistance Needs
Transfer ⬜ Independent
⬜ Set up
⬜ PartialAssist
⬜ Mechanical Lift
Ambulation ⬜ Independent
⬜ Set up
⬜ PartialAssist
⬜ Assistive Devise
Eating ⬜ Independent
⬜ Set up
⬜ Encourage Eating ⬜ Assist when needed
Toileting ⬜ Continent
⬜ Incontinent Toileting Program
⬜ Prompted
⬜ Habit
⬜ Scheduled
⬜ Bladder Retraining
Preferences and Needs:
