The Personal Information Form is a helpful tool to keep your loved one’s pertinent health and emergency contact information readily available on one sheet. Complete this form for any senior in your care. Having this form handy will alleviate stress in a moment of crisis. It’s also a great idea to give a copy to each family member.
PERSONAL INFORMATION FORM
Name:_______________________________________
Address:_____________________________________
Date of birth:__________________________________
Social security number:__________________________
Medicare number:______________________________
Insurance:____________________________________
Preferred hospital: _____________________________
Primary language:______________________________
Marital status:_________________________________
Children:_____________________________________
____________________________________________
Religion:_____________________________________
Church:______________________________________
Private companion:_____________________________
Advanced directives: Y/N
DNR: Y/N
Living will: Y/N
Where to find these documents:
____________________________________________
Person with power of attorney: ____________________
Medical diagnosis/diagnoses:______________________
____________________________________________
Allergies:_____________________________________
Medications and dosages:_________________________
____________________________________________
Physicians and specialists:________________________
____________________________________________
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Allison Gould, ESME’s Caregiving Resource Guide, is a licensed clinical social worker. For many years, her work focused on adolescents and their families. She currently provides outpatient counseling services to people aged 65 and older, as well as to their caregivers, at the Center for Healthy Aging at Northern Dutchess Hospital in Rhinebeck, New York.
Please feel free to contact us with any comments or questions.
