Personal Information Form for Seniors in Your Care


Personal Information Form for Seniors in Your Care

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:________________________

____________________________________________



Photo credit Shutterstock.com

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.


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