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
Date of birth:__________________________________
Social security number:__________________________
Preferred hospital: _____________________________
Advanced directives: Y/N
Living will: Y/N
Where to find these documents:
Person with power of attorney: ____________________
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.