Name of Care Recipient: _____________________

Please call me: ___________________

My Day Begins at: _______________

The tasks I need help with are as follows:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

The best time of the day for me is: _________________________________________________________

The most difficult time of the day for me is: _______________________________________

I usally end my day around: ____________________________________________________

The following are tasks I need help with:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Meals:

Breakfast:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Lunch:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Dinner:

___________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________________

In between snacks:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

My favorite beverage is:___________________________________________________________

I like my coffee or tea prepared: ______________________________________________________

I also enjoy: __________________________________________________________________

Special dietary needs:

__________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Special utensils :________________________________________________________________

Foods I am allergic or sensitive to are:

___________________________________________________________________________

___________________________________________________________________________

Foods I don’t like are:

___________________________________________________________________________

___________________________________________________________________________

My favorite food preferences are:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

I enjoy eating my meals served in (room): _____________________________________________________

I enjoy my caregiver eating with me: Yes __________ No _ _____

My favorite restaurants (and you may order out from them) are:

Name: ___________________________Address: _______________________________________

Name: ___________________________Address: _______________________________________

Name: ___________________________Address: _______________________________________

Name: ___________________________Address: _______________________________________

For list of family, personal contacts, physicians and other professionals, please read our
emergency information list.

Things I need help with (please describe):

Keeping Clean and presentable: ______________________________________________________

Toileting: ____________________________________________________________________

Bathing: _____________________________________________________________________

Waling: _____________________________________________________________________

Climbing Steps: ________________________________________________________________

Getting in and out of bed: __________________________________________________________

Housework: ___________________________________________________________________

Making and receiving phone calls: ____________________________________________________

Walking: ___________________________________________________________________

Taking medications: _____________________________________________________________

Transportation: __________________________________________________________________

Shopping ____________________________________________________________________

Eating: ______________________________________________________________________

Cooking: ____________________________________________________________________

I am most comfortable wearing: ______________________________________________________

__________________________________________________________________________

Going out to an appointment I like to wear:

___________________________________________________________________________

___________________________________________________________________________

Going out on an errand I like to wear:

___________________________________________________________________________

While in my home I like to wear:

___________________________________________________________________________

Going to church or temple I like to wear:

___________________________________________________________________________

___________________________________________________________________________

Special appliances, health care items, or aids I use:

Wig: ____________________ Makeup: ___________________ Cane: ________________

Walker: ____________________Wheelchair: ___________________ Mobile chair: _____

Eyeglasses: ____________________Incontinence pads / adult diapers: _____________

Hearing Aid: ___________________ Dentures: ______________Oxygen: ____________

Commode: ____________________ Walker: _________________________________

Special shoes, socks, etc.:_______________________________________________

Other:_________________________________________________________________

_

Crafts and hobbies .
Television Programs .
Radio Programs .
Music .
Exercise .
Musical Instruments
played		 .
Languages spoken .
Favorite topics for
conversations		 .
Meaningful life
experiences		 .
Travel experiences .
Memorable childhood
experiences		 .
Marriage .
Family .
Religous & Spiritual
background		 .
Accomplishments .
Other interests .

I am involved in the following community programs:

——————————————————————————————————————————-

——————————————————————————————————————————-

——————————————————————————————————————————-_

My disposition:

Caregivers enjoy caring for me because:

________________________________________________________________

________________________________________________________________

Caregivers have difficulty with me because:

________________________________________________________________________________________________

________________________________________________________________________________________________

 

Name of medication or vitamin ,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc. .
Dosage .
Times given: _____times per day at _____________________________________
Taken with fluid, after food or before eating ,
Special instructions ,

 

Name of medication or vitamin ,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc. .
Dosage .
Times given: _____times per day at _____________________________________
Taken with fluid, after food or before eating ,
Special instructions ,

 

Name of medication or vitamin ,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc. .
Dosage .
Times given: _____times per day at _____________________________________
Taken with fluid, after food or before eating ,
Special instructions ,

 

Name of medication or vitamin ,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc. .
Dosage .
Times given: _____times per day at _____________________________________
Taken with fluid, after food or before eating ,
Special instructions ,

 

Name of medication or vitamin ,
Form: liquid, tablet, capsule, injection, breathing treatment, bandage change, etc. .
Dosage .
Times given: _____times per day at _____________________________________
Taken with fluid, after food or before eating ,
Special instructions ,

Author

  • Ms. Mitchell began her full-time caregiving experience in the early eighties when her husband was diagnosed with cancer. Later on she became the primary caregiver for her father, along with her mother who had become critically ill from burnout prior to her dad’s passing. In recent years, she cared for several friends with AIDS while continuing to care for her mother and actively providing support, information, referrals and resources for caregivers.

    Gail's leadership on the Internet and her success with Empowering Caregivers led her to found National Organization For Empowering Caregivers (NOFEC) INC in 2001.

    Prior to founding NOFEC, she created the iVillageHealth Chat: Empowering Caregivers, which she hosted for over 5 years. Within a month of hosting she created Empowering Caregivers: www.care-givers.com in 1999 as a resource for caregivers around the globe. Over three million visitors have frequented the website.

    She has presented at national and international care-related conferences and programs and has been a keynote speaker for many programs as well.

    Ms Mitchell has assisted thousands of caregivers online and offline in ways to empower themselves in their roles in caring for loved ones.

    For a list of clients and/or her resume, please contact info@care-givers.com

    Gail's articles have been published in many venues nationally and in Canada. Presently, she is a member of American Society on Aging and National Quality Caregivers Coalition.

    Gail has discovered that there is life after caregiving: She has become a successful ceramic artist and installation artist. She created Crystal Illumination Art to bring the transformative quality of illumination, light and color to the human experience and celebrate its ability to inspire, heal and nourish our physical, mental, emotional and spiritual well being.

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By Gail Mitchell