<p>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.</p><p><strong>PERSONAL INFORMATION FORM</strong></p><p><strong>Name:_______________________________________</strong></p><p><strong>Address:_____________________________________</strong></p><p><strong>Date of birth:__________________________________</strong></p><p><strong>Social security number:__________________________</strong></p><p><strong>Medicare number:______________________________</strong></p><p><strong>Insurance:____________________________________</strong></p><p><strong>Preferred hospital: _____________________________</strong></p><p><strong>Primary language:______________________________</strong></p><p><strong>Marital status:_________________________________</strong></p><p><strong>Children:_____________________________________</strong></p><p><strong>____________________________________________</strong></p><p><strong></strong></p><p><strong>Religion:_____________________________________</strong></p><p><strong>Church:______________________________________</strong></p><p><strong>Private companion:_____________________________</strong></p><p><strong>Advanced directives: </strong>Y/N <strong></strong></p><p><strong>DNR: </strong>Y/N<strong></strong></p><p><strong>Living will: </strong>Y/N<strong></strong></p><p><strong>Where to find these documents: </strong></p><p><strong><strong>____________________________________________</strong></strong></p><p><strong>Person with power of attorney: ____________________</strong></p><p><strong>Medical diagnosis/<strong>diagnoses</strong>:______________________</strong></p><p><strong>____________________________________________</strong><br><strong></strong></p><p><strong>Allergies:_____________________________________</strong></p><p><strong>Medications and dosages:_________________________</strong></p><p><strong>____________________________________________</strong><br><strong></strong></p><p><strong>Physicians and specialists:________________________</strong></p><p><strong>____________________________________________</strong></p><hr><p><br></p><p><span style="font-size: 11px;">Photo credit Shutterstock.com</span></p>