GETTING ORGANIZED FOR ELDER CARE

RECORDS AND INFORMATION

Consider completing this document then updating it annually when taxes are prepared. Keep a copy with your personal records and give a copy to the person(s) you have identified to manage your affairs if you become unable to do so. A copy of your Durable Power of Attorney and Living Will should be attached.

DATE: ______

Personal Information / Name: / Name:
Name
Street Address
City, State, Zip
Mailing Address
Phone Number
Social Security #
Medicare Number
Medicaid Number
Military ID Number
Driver’s License #
Emergency Contacts:

Family

Name
Phone Number
Name
Phone Number

Name:

/ Name:
Name /
Phone Number

Neighbors

Name
Phone Number
Name
Phone Number
Name
Phone Number

Clergy

Name
Phone Number
Name
Phone Number

Friends

Name
Phone Number
Name
Phone Number
Name
Phone Number
Name
Phone Number
Important Documents / Name: / Name:
Note Location of Documents
Bank Related
Safe Deposit Box & keys
Check Register
Savings
Other:
Legal
Will
Advance Directives
Living Will
Durable Power of Attorney
Property
Finance
Property Deed(s)

Miscellaneous

Divorce Records
Contracts
Partnership Agreements
Other

Notes: ______


GETTING ORGANIZED FOR ELDER CARE

ASSET CHECKLIST

DATE: ______

Dollar Amount / Account
Number / Has / Doesn’t
Have / Location
Cash Assets
Stock Money Funds
Checking Accounts
Savings Accounts
Stocks
Bonds
Treasury Bills
Municipal
Bonds
Mutual Funds
Real Estate
Residential
Commercial
Art
Antiques
Jewelry
Homeowner’s insurance
Car Insurance
Renter’s
Insurance
Life Insurance
With cash value
Life Insurance
Term only
Mortgages’ Held
Notes held
LIABILITIES
Mortgages
Personal Loans
Credit Cards
Car Loans
Boat Loans
Business Loans


GETTING ORGANIZED FOR ELDER CARE

LEGAL & FINANCIAL ADVISORS

ADVISOR / ADDRESS / NOTES
Attorney
Accountant
Financial Advisor
Banking Information / Bank / Branch Location
Checking
Account Number
Savings
Account Number
Investment
Account Number

NOTES:

______


GETTING ORGANIZED FOR ELDER CARE

RECORDS AND INFORMATION

LEGAL DOCUMENTS

ITEM / HAVE / LOCATION / NEED TO GET
Birth Certificate
Marriage Certificate
Deed to House
Will(s)
Tax Records
Advance Directives
Living Will(s)
Power of Attorney
Property & Financial Issues
Mortgage Papers
Apartment Lease
Automobile Title
Boat Title
Appraisals/Jewelry
Insurance Policies
Life Insurance
Health Insurance
Funeral Insurance
Auto Insurance
Other


GETTING ORGANIZED FOR ELDER CARE

MEDICAL AND HEALTH ISSUES

DATE: ______

HEALTH CARE PROVIDERS FOR: ______

Name / Address / City/State/Zip / Phone/Fax / Alternate Phone
Primary Care Physician
Physician Specialist
Physician Specialist
Physician Specialist
Personal Care Attendant
Hospital
Medical Record #:
Pharmacist


GETTING ORGANIZED FOR ELDER CARE

MEDICAL AND HEALTH ISSUES

DATE: ______

MEDICATION RECORD FOR: ______

DRUG NAME / Refill Number / Prescribing Physician / Phone Number
Dosage / With food o / Without food o / # of times daily
Reason for Drug / Possible Side Effects / Patient’s Reaction / Pharmacy Name
Pharmacy Phone Number / Emergency Phone Number / Emergency Phone Number / Emergency Phone Number
DRUG NAME / Refill Number / Prescribing Physician / Phone Number
Dosage / With food o / Without food o / # of times daily
Reason for Drug / Possible Side Effects / Patient’s Reaction / Pharmacy Name
Pharmacy Phone Number / Emergency Phone Number / Emergency Phone Number / Emergency Phone Number
DRUG NAME / Refill Number / Prescribing Physician / Phone Number
Dosage / With food o / Without food o / # of times daily
Reason for Drug / Possible Side Effects / Patient’s Reaction / Pharmacy Name
Pharmacy Phone Number / Emergency Phone Number / Emergency Phone Number / Emergency Phone Number
DRUG NAME / Refill Number / Prescribing Physician / Phone Number
Dosage / With food o / Without food o / # of times daily
Reason for Drug / Possible Side Effects / Patient’s Reaction / Pharmacy Name
Pharmacy Phone Number / Emergency Phone Number / Emergency Phone Number / Emergency Phone Number


GETTING ORGANIZED FOR ELDER CARE

PERSONAL CARE PLAN

Identify the frequency of care need and who can attend to it. Include family supports, church volunteers, neighbors, and agency help, etc. Identify what gaps exists and how they can be filled.

CARE
NEED / MONTHLY / WEEKLY / DAILY / AS NEEDED
Meal Preparation
Grocery Shopping
Bathing Assistance
q  Wash hair
q  Shave
q  Dental Care
q  Dressing
q  toileting
q  help in & out
Transferring
Exercise
Laundry
Visiting
Transportation
Medical Appts.
Housecleaning
Paperwork
Errands
Bill Payment
Banking
Recreation
Church
Other

For more information about Eldercare services though the Employee Assistance Program, call Brenda Wilson, LCSW, Eldercare Specialist (434) 924-5483. EAP Services are Free to all employees, their families and all contacts are Confidential.

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