Whether you live long distance or are directly caring for your loved one, it is important to have detailed information readily at hand for emergency purposes. You must know what documents are needed and where they are located. This information should be accessible for yourself and those who will be caring for your loved one if you are not available.

Please remember to keep all this information up to date. By preparing this information, you be insuring that you are better prepared should emergencies arise. We encourage you to print out these pages, keeping them in a safe place, preferably a binder or envelope. Click on the links to access the forms for printing

Carerecipient:

Name:_____________________
Nickname:_______________
 .
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Phone: ___________________
Social Security #:_________________Blood Type: ____
Disease(s)/ Illness/ Condition:
 _____________________ _______________________
______________________ _____________________ _______________________
Organ Donation Status: __________________________________________________
Other Important Info: _____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Caregiver:

Name:_____________________
Nickname:_______________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Relationship To Carerecipient: ____________

Caregiver:

Name:_____________________
Nickname:_______________
 .
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ______
Relationship To Carerecipient: ____________

Emergency Phone Numbers:

911
Police: __________________
Fire: ________________
Ambulance: _______________ Hospital: __________________
Others: ______________________________________________________________

 

Spouse, Significant Other, Relative, Friend or Neighbor:

Name:_____________________
Nickname:_______________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Relationship To Carerecipient: ____________

Spouse, Significant Other, Relative, Friend or Neighbor:

Name:_____________________
Nickname:_______________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Relationship To Carerecipient: ____________

Doctor(s):

Name:________________________________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

 

Name:________________________________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

 

Name:________________________________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Home Phone:_________________Business Phone:________________ Ext:  ___
Type Of Doctor: ____________

Pharmacy

Name:________________________________
Address______________________________________________
City: _____________________
State: _______
Zip: ________
Phone:________________ Hours: ____________________________________
Medications: ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________
Allergies ____________ ________________ _________________
Allergies To Medications: ______________ _______________ _______________
Special Instructions: _______________________________________________________________ ________________________________________________________________________________

Health Insurance Company(s):

Medicare

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

Medicaid

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

Medigap

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

Workers Compensation

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

Social Security Disability

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

Veterans Administration

 

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

Other

Policy #: ___________________________ Phone #: ___________________ Ext: ____
Contact: _____________________ Address: ______________________________
City: __________________________ State: _________ Zip: _________

 

 

Copyright 2000 by Gail R. Mitchell

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