Summary

Primary Care Provider

Name
Clinic/Hospital

Emergency Contacts

Name
Phone
Name
Phone
If I need subacute rehabilitation in a SNF, I would like to go to:
Skilled Nursing Facility
If I need help in my home, I would like to use:
If I need help in the home, I would like this group to be contacted:
If I need low-cost help in the home, I would like this group to be contacted:
Information about pharmacies:
Pharmacy #1 (local)
Pharmacy #2 (w/ mail order)
People who might be able to help with:
Collecting my mail

Picking up newspapers

Checking on bills to be paid

What can I do to make my home safer?

Attach the rug ends to the floor to keep them flat

Remove any small rugs

Remove, or have carpeting with ridges and bubbles stretched

Identify thresholds between rooms that are elevated

Check any areas where you stub your toe

Install handrails in bathrooms. Put nonslip strips or a rubber bath mat in the tub

Try to move items that are often used to convenient spots

Individual states or local governments have resources that can help people over the age of 65 in their area. I've chosen the following Area Agency on Aging if I need help:

Name and contact information of a trusted financial contact:

If people are concerned about my driving,

My physicians can be asked about my driving
I would like to have a younger loved one or friend drive with me once a month to check on my driving
I would like to be evaluated by a senior driving evaluation group
I would like to reduce the need to drive by considering options such as home delivery

If I start having problems remembering my pills or doing my daily tasks, here are some possibilities to help.

Write notes and label items that get use.
Get organized so I do the same regimen every day.
Think about having someone come in once a week or more as needed to help with filling pill boxes and ensuring that medications are taken.

Consider getting a medical alert or ID bracelet with your name and an emergency phone number on it. Do NOT put your own phone number on it. It might be best to put a number of someone local who could pick you up if needed.

If it would help me, I would like to get a medic alert bracelet in the future.

Friends or family who could help at home:
Name and Contact Info

A caregiver, homemaker, or home health aid is sometimes needed to help with day-to-day activities. If I need help in my home, I would like to use:

Home care assistant

My goal is to:

I am open to having someone help me in my home if it means I can stay there longer.

I would like to move in with

My goal is to remain in my home as long as it is safely possible.

I am willing to move into a senior community.

I would like to talk to about my future health care plans with:
Welcome
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