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Form #: Date Revised: Date Implemented: © 2005 Manhattan Retirement Foundation Inc.
Needs and Preferences
Escort for trips away from the community Family member who will assist:
Mail ⬜ Independent ⬜ Open for resident
Resident handles own Business Mail:
Business Mail forwarded to : Spiritual Needs ⬜ Active ⬜ Important
⬜ Yes⬜ No
⬜ Read to resident
⬜ Yes⬜ No ⬜ Inactive
Attend religious services in LOCAL community ⬜ Yes If yes, what time and where:
Attend religious services in THIS community ⬜ Yes If yes, what time and where:
Offer Communion ⬜ Yes Alcohol and Tobacco use:
⬜ No ⬜ No ⬜ No
Miscellaneous Information:
Activities of Daily Living (indicate resident’s preferences for each activity)
