This is a compilation of all the answers you provided throughout the five sections. We encourage you to fill everything out — and then email and print out a copy for safekeeping. Also, this is not set in stone; you can come back to revise it any time.

Primary Care Provider

Emergency Contacts

Information about pharmacies

People who might be able to help with:

What can I do to make my home safer?

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,

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

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.

Friends or family who could help at home:

A caregiver, homemaker, or home health aid is sometimes needed to help with day-to-day activities.

My goal is to:

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