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SENIOR LIVING COMMUNITIES DECISION-MAKING GUIDE

Includes

Personal Information Organizer

By Ronit Cohen, PT

Your Personal Senior Referral Agency

541-954-2602 www.AHomeToFitYou.com

Senior Living Communities Decision-Making Guide

TABLE OF CONTENTS

Welcome 4

When is it Time to Take Action? 5

Is Senior Living Community the Right Choice? 6

Which type of Senior Living Community Fits Best? 10

What is Affordable? 11

Senior Living Community Selection Process 14

What to look for when touring Senior Living Communities? 16

Care Community Assessment Form 17

Before you Make the Move Checklist 20

After the Move Checklist 21

Personal Information Organizer 22

www.AHometoFitYou.com [email protected]

Copyright 2018 A Home to Fit You

http://www.ahometofityou.com/


WELCOME

Whether you are in the initial stage of information gathering, or you have already made the decision to look for a care community to fit you, the process can be stressful, overwhelming and confusing. There are many parameters to consider such as care needs, preferred location, types of care communities, and financial ability. This guide holds an abundance of information and step-by-step worksheets to help you simplify the process.

Each chapter open with explanation outlining the purpose of gathering specific information and how you use it in the process of finding the right home that would best fit you or your loved one. I have endeavored to make it clear and easy to follow. I welcome any questions or suggestions you may have to improve it for the next person.

Fill in the information in any order that make sense to you, but make sure not to skip any chapters (unless it is clearly not relevant to your situation), as each is important for the process you are about to go through.

If you are gathering information for a family member, it is important for you to include this person in the process. It assist you in providing the most accurate information regarding their care needs as there are many details that only this person will know. More importantly, it is every person’s right to take part in a decision making process that impact them. However, if the person in need of care has cognitive deficits, while it is important to include him or her in this process, make sure the information you collect is accurate.

I hope that by providing this decision making guide, I will be able to alleviate some of your stress and make the task of looking for a senior living community clearer and more logical.

Ronit Cohen, PT

Owner, A Home to Fit You





WHEN IS IT TIME TO TAKE ACTION?

Most people are in crisis mode when they look for care community, waiting as long as possible to stay at home, when a health emergency happens that requires an immediate change in their living situation.

If recognize the warning signs that indicate a change is already in process, you could start planning early and explore the different care options. You may be able to provide the needed help at home form a family member or form outside for-pay professional health agency. Or, you may want to start looking now for the right care community and avoid the crisis.

Check all that apply

My Loved one is experiencing the following

_______ Frequent falls

_______ Frequent medication mistakes or forgetting to take medication

_______ Neglect of personal hygiene

_______ An unsafe or unclean home environment

_______Not eating or drinking regularly

_______ Needs help at night

_______ Unsafe behavior such as forgetting to turn off the oven or leaving doors unlocked

_______ Asking same questions again and again

_______ General confusion, disorientation of time and place

_______ Getting lost in familiar surrounding

_______ wandering from home despite safeguards put in place

_______ Losing touch with friends

_______ Becoming paranoid of others or accusing others for missing items

If you checked at least one of the above signs, you need to start the conversation with your loved one and other family members who are involved in the process as to whether more help at home will be enough or a care community is the right choice

Check all that apply to you as the main caregiver of your parent(s):

_______ I disagree with my parent about his/her care needs

_______ I worry about my parent’s safety when I am not there





_______ I take too much time off from work to attend to my parent’s needs

_______ My own family (kids, spouse) complains that I don’t spend enough time with them

_______ I argue with my siblings about who is responsible for providing care for our parent(s)

If you checked at least two of the above, you may be getting burned out by being the caregiver for your parent(s) and it may be time to start a conversation about finding the right senior care community for your parent.

IS SENIOR LIVING COMMUNITY THE RIGHT CHOICE?

The conversation about whether or not to move into a care community should be addressed openly and honestly. The philosophy of “aging in place” in the family home is today’s growing trend and many consider it as the choice that fit them. Those who have family members who are able to provide the needed help with household activities (cooking, cleaning, laundry, etc.), shopping or doctor’s appointments are more inclined to stay at home. Others can afford hiring an in-home care agency to provide the needed help.

However, there are many reasons why aging in place may not be your option. The choice to move to a care community, where all your physical, social and medical needs can be met under one roof, may be the decision you will need to make

Mark by each item one of the following:

F: Family can provide this help

H: you can pay for Hired help

C: You would rather a Care Community help

______ Help with chores outside the home: shopping, errands, or transportation

______ Help with household chores: cooking, cleaning, laundry

______ Help with activities of daily living (ADL): dressing, bathing, toileting

______ Outing to socialize with friends or attend activities outside the home

______ Supervise to prevent falls

______ Supervise the care that is provided by others (not family)

______ help with administering medication

______ Take to doctor appointments and monitor medical issues






In your loved one and your opinion, possible reasons and advantage of aging in place (staying at home with provided/ hired help)

______ There is no place like home

______ I like my privacy

______ I am not interested in social activities

______ I don’t want to share my bathroom with strangers

______ It is cheaper to get the care at home

______ I don’t want to spend all my money and I would like to leave some for my kids

______ I have more say about my care and who will be my caregiver

______ I will get more attention and better acre at home

______ I know my parent would die if I move him/her from home

______ I promised my parent I would never move him/her to a nursing home

Other_______________________________________________________________________________________________________________________________________________________


In your loved one and your opinion, possible advantages of care community are:

_______ Freedom from responsibilities and chores related to maintaining your home and garden

_______ No need to make safety adaptations to my home (grab bars, ramp etc.)

_______ Can be closer to family members

_______ Decreased isolation and loneliness that may lead to depression

_______ Many social activities and opportunity to make new friends

_______ Transportation provided by the community eliminate the need to drive

_______ Easy access to health care professional (nurse)

_______ Caregiver available 24/7 for hands on help

_______ Decrease stress of family members who are the main caregivers

_______ Decrease fall risk

_______ Cheaper than hiring 24/7 care at home





TYPES OF SENIOR LIVING COMMUNITIES AND HOW THEY DIFFER

There are many factors to consider when going through the process of choosing the best care community that would fit you or your loved one. It will be important to consider care needs and personal wants as well as anticipate possible changes in care needs with time.

Health and physical ability- Are you medically stable? Do you struggle with many health issues? How much help do you need with ADL (activity of daily Living) and mobility? Do you anticipate changes in your medical and physical care needs in the future? Some are communities can accommodate most changes in your medical care needs, or have the different level of care in one location which would allow you to remain in the same community/ campus (not the same room).

Location- Are you looking to be near family, friends, doctors, church or senior center?

Cost- It is important to have clear and accurate picture of your finances: your income, assets and debt, as well as your ongoing expenses that won’t change regardless of where you choose to live. Your financial situation will play a big part in the decision making process because what you can afford and how for long is one of the most important components in selecting the right care community for you or your loved one.

To allow you better understand what type of acre community fits your needs and preferences, before you continue to read the following information about t=each community, “jump” forward to the chapter titled “Care Community Selection Process.” The information you glean from this chapter will help you understand the level of care needed. To assist you, in the next section are descriptions for the different type of care communities.

For more in-depth information about each type of community, who they serve best and who would not be appropriate, go to the website www.AHomeToFitYou.comm

Independent Living

These are typically apartments or condominiums that are exclusive to seniors of minimum age. They offer one to three daily meals, weekly cleaning service, group amenities such as club houses or community rooms, laundry rooms, recreation and planed socials and transportation to medical appointment and shopping. Residents are active, mobile (canes and walkers are usually fine) and interested in peer group interaction and socializing. Most of them operate on a monthly rental basis and have several apartment models.



http://www.ahometofityou.comm/



Assisted Living facilities (ALF)

These offer a private apartment with a kitchenette, private bathroom, three daily meals and weekly cleaning service. In addition, they offer 24/7 caregiver help with mobility and activity of daily living (ADL) such as dressing, bathing and toileting. They have an RN on site and provide medication administration. They offer varied social activities and transportation to medical appointment or to social outing. They operate on a monthly rental basis and their charges vary, based on the apartment size and the level of care needed.

Adult Foster Home (AFH)

A community located in a family home that accepts up to five elderly or disabled residents. They offer a private or semi-private bedroom and shared bathrooms. They provide 24/7 caregiver help with all ADL, medication administration, three home style cooked meals and al household chores but very few structured social activities.

Residential care facility (RCF)

A community of up to 15 residents; some RCFs are composed of few houses with 12-15 residents in each (referred as communities or neighborhoods). They offer private or semi-private rooms and shared or private bathrooms, cleaning services and laundry. They offer RN on site and 24/7 caregivers who provide personal care (ADL), medication administration, daily meals and social activities.

Memory Care Community

They include a secure environment, trained staff, and special program designed for the particular needs of Alzheimer’s and other memory related Dementia. They offer private or semi-private rooms with private or shared bathrooms, cleaning services and laundry. They offer an onsite RN and 24/7 caregiver who provide personal acre (ADL), medication administration, daily meals and social activities.

Nursing Home

A nurse is on duty at all times and a doctor visits once or twice a week. They offer shared rooms and shared bathrooms, cleaning services and laundry. There are 24/7 caregivers who provide personal care (ADL), medication administration, daily meals and social activities. A nursing home is an option when the level of care is heavy and may require more than one person to assist at all times or hen there are medical conditions that require the attention of a nurse and a doctor on a regular basis.





WHICH TYPE OF SENIOR LIVING COMMUNITY FITS BEST?

Now that you have a better understanding of the different type of care communities and the distinction between them, you may have an idea which type of care community fits your care needs. In evaluating the various care community options within the same category, there are many things to consider. What is important to you? What should you look for? What should you expect? the more you are clear about what is important to you, the easiest it will be to choose the best home to fit you.

For Independent Living and ALF communities, the following will help you with choosing the one community out of the many to choose from.

Location


I would like to be close to

_______ my children/family

_______ my friends

_______ public transportation

_______ my church

_______ shopping center

_______ community cultural activities

_______ my doctor’s office

_______ park and walking paths

Once you mark what is important to you, go back and priorities your choices: number one being the most important consideration. When you visit care communities, select at least the top three, as there may be a tie between two or more communities you like exactly the same.

When contemplating between Adult Foster Home and Assisted Living, consider which of the following is important to you

Amenities and service you would like to have


_______ all meals provided

_______ some meals provided

_______ kitchen or kitchenette

_______ private bathroom





_______ parking availability

_______ transportation to medical appointments and/or shopping

_______ home care agency on premises (extra help for private pay)

_______ laundry or housekeeping service weekly

_______ social, exercise, or entertainment activities on premises

_______ organized trips or activities off premises

_______ a small home like setting with few residents

_______ a large campus style setting

_______ ability to keep a small pet

_______ all level of care (continuing care) in the same location/campus

_______ smoking allowed

WHAT IS AFFORDABLE?

It is important to have knowledge of your assets and income as well as your expenses, so you can find the best care community that also fits your financial resources. Before you dive into your financials, I would like to take a moment to explain the different payment options; private pay vs. Medicaid (or state) pay, as this will be one of the first questions you will be asked by any care community.

Many care communities take both private pay and Medicaid pay clients (do not confused Medicare which is your health insurance and does not pay for care communities). However, since Medicaid pays less for the same level of care as a private pay, each community has only a few spaces available for Medicaid clients. If you are not eligible for Medicaid (eligibility is based on care needs and income) and you calculate that the income you have would last for a while as a private pay client, you can start out as a private pay client. Once your funds are exhausted, you can become a Medicaid client without this status change affecting the service you are receiving. This is what we call “spend down”. Some communities who will accept you as a spend down’ will ask for at least one or two years of private pay.

Please contact me for more information regarding Medicaid eligibility if you are all confused about this





Affordability Notes

Assets (total value)

Home_____________________________

Car _______________________________

Saving account______________________

Checking account ___________________

Stocks or Bonds _____________________

Other _____________________________

__________________________________

__________________________________

__________________________________

Total Assets ________________________

Monthly income

Rent ______________________________

Long term care insurance (per policy) ____________________________

Pension ____________________________

Annuity ____________________________

Alimony ___________________________

Social Security ______________________

Other _____________________________

__________________________________

__________________________________

__________________________________

Total Monthly Income _______________

Additional cost while living in the care community: some of the following is included in your monthly payment to the care community. For what is not included, write (or estimate) the monthly expenses.

Meals____________________________

Housekeeping______________________





Laundry services ___________________

Personal care assistance ______________

Telephone _________________________

Internet/ cable _____________________

Parking ___________________________

Transportation (Ride source, taxi) _________________

Other _____________________________

__________________________________

__________________________________

Personal monthly expenses (known or estimated amount)

Home taxes and insurance ________________________

Health Insurance ___________________

Medications _______________________

Incontinent supply __________________

Personal hygiene (soap, shampoo etc) _______________

Hair cut and nail care _______________

Subscriptions (newspaper, magazine) ________________

Clothing __________________________

Outing (restaurant, movies) ________________________

Loan/ debt payment ________________

Other ____________________________

_________________________________

_________________________________

Total monthly expenses ____________________________

Total monthly gross income _________________________

Minus

Total monthly expenses ____________________________

= Total net monthly income ________________________





Total monthly charge by the care community _________________________

If you have a car or a house that you plan to sell, estimate your equity from the sell. Do not calculate this amount as your income. Once you know what the monthly expenses would be at the community you choose as the best fit for you, you can calculate how many months you can pay from the total income you have plus the sale of the house.

SENIOR LIVING COMMUNITY SELECTION PROCESS

While you gather all the information you need to help you find the home that fit you, the care community, by their rules and regulation, is required to complete their own assessment of your care needs. They have rules to follow that guide them to ensure they are able to provide the care you need. In addition to assessing your care needs, small care communities, such as Adult Foster Homes, may want to determine if you would be a good fit with their current residents.

The assessment process is collection of questions and /or hands-on assessment that will help the community determine your level of care, what your habits are, behavior patterns, and personality. If you are helping a family member look for a care community, you may not know all of the answers for these questions. Therefore, it is important for you to fill out this information together with your loved one. This will also help you understand the level of care your loved one need and what may be the appropriate type of care community to consider

Medical information

Use the Personal Information Organizer at the back of this guide to list this information. It includes your medical diagnosis, current medication list, name of doctors who are involved in your care.

Do you need assistance with medication administration and if yes, what kind (weekly setting, daily reminders, unable to manage at all by oneself) ____________________________________________________________________________________________________________________________________________________________

ADL (Activity of Daily Living)

For each item write I (Independent) A (needs assistance but can do some of it by yourself)

D (Dependent: cannot do at all, even with help). If A, please give more details of what kind of help is needed (setting up, reminder, can put hands inside shirt but can’t pull over the head etc.)

Dressing: upper/ lower body, shoes ____________________________________________________________________________________________________________________________________________________________





Grooming: brushing hair, teeth/dentures ______________________________________________________________________________

______________________________________________________________________________

Bathing: Do you need help with showering? If yes, what kind? Do you need a shower chair?

____________________________________________________________________________________________________________________________________________________________

Mobility:

Transfer in and out of bed________________________________________________________

Getting in and out the couch/ chair_________________________________________________

Walking: Do you use a cane, walker, and wheelchair __________________________________

If walking, do you need supervision ________________________________________________

Any falls (and how many) in the last 6 months? _______________________________________

______________________________________________________________________________

Toileting

Incontinent of urine? ____________ BM ____________________

Use Depends? During the day________________ at night_______________________________

History of bladder infection_______________________________________________________

Nutrition and diet

Any special diet (diabetes, allergies) ________________________________________________

______________________________________________________________________________

Foods you do not like ______________________________________________________________________________

______________________________________________________________________________

Night-time needs

What time you go to bed ___________ what time you get up in the morning_______________

Do you sleep through the night? ____________________________________________________

Do you get up at night to go to the bathroom? How many times? Would you be willing to use a bedside commode? _____________________________________________________________

_____________________________________________________________________________





Communication

Hearing aid/ hard of hearing ______________________________________________________

Vision/ glasses _________________________________________________________________

Memory and cognition

Short term memory ____________________________________________________________

Long term memory _____________________________________________________________

Safety and judgment ____________________________________________________________

_____________________________________________________________________________

Diagnosed with Dementia? _______________________________________________________

Behavior

Verbal aggression _______________________________________________________________

______________________________________________________________________________

Physical aggression ______________________________________________________________

______________________________________________________________________________

Inappropriate sexual behavior _____________________________________________________

______________________________________________________________________________

Social activities and interests

______________________________________________________________________________

______________________________________________________________________________

Member of a church or organization________________________________________________

WHAT TO LOOK FOR WHEN TOURING SENIOR LIVING COMMUNITIES?

When touring care communities you will be shown around and your attention will be pointed toward everything that makes a good impression on you. It is important that you keep a record of your impressions; what did you like and why. At the same time, it is important to ask questions about the things that may not be visibly obvious or information that may not be shared with you. Keep in mind that every care community has its strength and weaknesses and it is your responsibility to gather the information that is most important to you.





The following is a list of things to observe and questions o ask. Feel free to make a copy of this section and fill it in for each community you visit as it will allow you to compare apple to apple when you come to the last step of your search in choosing the right home to fit you.

You can make a few copies of the following Care Community Assessment Form and use one for each community you are visiting.

How many visits should you make?

Ideally, you should want to visit more than once if you have time. On the first visit, you will meet with the person who will show you around and answer all your questions. If you are looking for a place for your loved one, it will be important to come back to the communities you like the most with that person, to give him or her the option of being part of the decision making process.

When to visit?

Visiting during meal time is a good choice as it will allow you to experience the food and see more residents. It is especially important in Adult Foster Homes to have the person who will become the resident visit during lunch to allow him or her to get to know the other residents. It will also allow the current residents to give their input into the assessment process that is being done by the care community.

CARE COMMUNITY ASSESSMENT FORM

Name of care community ________________________________________________________

Date and time of visit ___________________________________________________________

Current residents: Are they friendly, engaged, active? __________________________________

______________________________________________________________________________

Staff: are they friendly, attentive, interact with residents? ______________________________

____________________________________________________________________________________________________________________________________________________________

If you don’t visit during meal time, ask if there is activity going on and ask to observe it. Record your impression form the instructor and the residents ________________________________

____________________________________________________________________________________________________________________________________________________________

What type of activity the community offer (are there any that you may be interested in)?





__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Observe

There is a lot of information you can gather just by looking around and opening your eyes, ears and nose.

Cleanliness: does the place look clean, smell good and seems to be in good condition?

____________________________________________________________________________________________________________________________________________________________

Your potential room: its location, size, look, would you have enough room for the personal items you would want to bring with you _____________________________________________

____________________________________________________________________________________________________________________________________________________________

Outdoor space _________________________________________________________________

______________________________________________________________________________

Ask

There are many questions to ask. Quite a few answers have already been provided to you through the screening process preformed by the senior referral agency, as they would refer you to the community that most match your need and wants. The following are additional questions you may want to ask to be clear with the way the care is being provided.

Staff residents ration in the different shifts: day _______________________________________ evening_____________________________ night _____________________________________

What is the general staff turnover? _________________________________________________

______________________________________________________________________________

What training do you provide to your staff? __________________________________________

______________________________________________________________________________

Nurse on duty: hours/ days of nurse on premises ______________________________________

Responsibilities _________________________________________________________________

_____________________________________________________________________________

Who handle complaints and how are they addresses? __________________________________





____________________________________________________________________________________________________________________________________________________________

Who is in charge over the weekend? ________________________________________________

______________________________________________________________________________

How do you help the new residents acclimate? _______________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How do you keep the residents’ personal belonging safe and secure? _____________________ ______________________________________________________________________________

Ask about violations found during inspections in the last two years and how they are being addressed? ____________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Write down the information during the visit or shortly after, while it is still fresh in your mind. Trust your gut feeling; you may get all the answers to your questions right, but if something inside you tells you this may not be the fit for you, listen to that inner voice.

Give a final grade to each to each community from 1 (worse) to 5 (best) to help you with the final choice.

Grades

1- Not the place for me

2- Just okay

3- I liked some things

4- I like most of the things

5- This community fits me

Your final grade for the care community ____________





BEFORE YOU MAKE THE MOVE CHECKLIST

Some items on this list are meant to give you a general idea of how to approach this process. Other items are ones you should actually make sure to complete, and there is a place for the check mark of “done.”

● Take the time you need (or have) to do all your homework before you make your final

decision on the care community that fits you.

● If you find this process to be too overwhelming, confusing or stressful, consult a professional such as you family doctor or a senior referral agency.

● If you are the family member that is helping a loved one make the move, remember to involve that person, as much as possible and as appropriate in keeping with his or her abilities, and include them in the decision-making process.

● Work as a team with other family members and try to keep an open mind to opinions that are different than yours.

● Before you sign a contract with a care community, don’t assume the contract is “just fine” because everyone else (other residents) signed it. Do not hesitate to question what you are not clear about or negotiate terms you may not like.

____ Ask to review the “house rules” of the care community of your choice. You may discover rules you were not aware of and that may not correlate with your expectations or lifestyle.

____ Be familiar with the residents’ bill of rights that is mandated by the state. You can ask the community for a copy.

____ Look at the room you will be moving into and find out what furniture, if any, is being provided by the care community and what you will need to bring from home.

____ Remember you won’t be able to fit most of your home’s furnishings into the space you will be moving into. Make a list of the items that are the most important to you and that will make the space feel like home (think of anything that you can hang on the walls).

____ When deciding how to arrange the space, keep in mind it is important to avoid clutter. Consider the furniture you can place against the wall or the pictures you can hang on the wall.

*Consult the appropriate person in the care community for the safest way to arrange your space.





____ If possible, move as many items as possible (furniture, clothes, personal items, etc.) a day or two before the move-in day. It will make the physical move less hectic and it will make the emotional move a little easier when the space has personal items that give the familiar feel of home.

*Consider consulting with a senior move management professional who can help you with the overwhelming task of downsizing, arranging your new space, moving the furniture as well as with other services such as an estate sale, and the selling of your home.

*Do not schedule the move-in during the weekend. You may need the services of your doctor’s office, a pharmacy, the manager or the nurse of the care community, all of whom may not be available during the weekend.

* Try to schedule the move time mid morning.

*If you are helping a family member move in, free your day from all other commitments.

AFTER THE MOVE CHECKLIST

Keep in mind that emotional adjustment to your new home may take a minimum of three months. You (or your loved one) need to adjust to the new living environment, maybe a new bed, new schedule, new food, new people, and different caregivers. All this newness in addition to the great loss of everything that was part of his or her life: a home, independence, friends, etc.

*As a family member of the person who needs to relocate to a care community, do not be surprised if he or she exhibits anxiety, depression, sadness, or complains a lot. It is part of the adjustment.

*If the person who relocates has dementia, you may see an increase in confusion and disorientation due to the unfamiliar new environment.

_____Try to maintain old habits that would not be affected by the move such as: watching your favorite daily TV show, having afternoon tea time, your weekly call to a family member or a friend, etc.

_____As a family member, make daily visits to see that the care you are expecting is being provided and to spend quality time with your loved one.

*Remember that although the move is stressful on your parent or spouse, it frees you from being the caregiver and allows you to go back and be the spouse or the daughter/son. It may have a positive effect on your relationship.

_____Invite family and friends to visit your new home.

_____If you have any concerns regarding the care your love one is receiving, do not hesitate to talk to the manger or resident care coordinator.





_____Visit often, bring grandkids or pets if allowed, and stay positive and supportive of your loved one.

*Although you are no longer the main caregiver, no matter what amount you pay to the care community, it is your responsibility to always be involved and informed about your loved one’s care, medical changes, care need changes, etc. In big care communities where high turnover of caregivers is common, it is always important to be another set of eyes on the care plan and its execution.

PERSONAL INFORMATION ORGANIZER

This form will help you organize most relevant information that you will needs as you move into new home. Be sure to make a copy of your ID card, health insurance card, POLST, advance directive and any POA documents and attach to this form. Keep all originals, including birth certificate, passport, life insurance policy, home insurance policy, will and other legal documents you may have in one safe place. It’s probably a good idea to make copy for at least one family member so it will always be handy. Keep in mind that some of this information may not be relevant for you or your loved one.

Personal information

Full Legal name ________________________________________________________________

Home address _________________________________________________________________

Home phone number ____________________________________________________________

Cell phone number ______________________________________________________________

Date of Birth ___________________________________________________________________

Social Security Number __________________________________________________________

Driver’s License Number _________________________________________________________

Insurance information

Health Insurance Provider ________________________________________________________

Group Number _________________________________________________________________

Member ID Number _____________________________________________________________

Homeowner’s Insurance Provider __________________________________________________

Policy Number _________________________________________________________________

Auto Insurance Provider __________________________________________________________

Policy Number _________________________________________________________________

Life insurance Provider ___________________________________________________________





Policy Number _________________________________________________________________

Long Term Care Insurance Provider ________________________________________________

Policy Number _________________________________________________________________

Computer information

If you use a computer to access sites using your user ID and password (PW), list each site separately with its own ID and PW

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Bank and financial Information

List accounts by number and location (bank or investment company )

Checking ______________________________________________________________________

Saving ________________________________________________________________________

Annuity/ IRA? Other ____________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Credit Card ____________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical information

Doctors’ Information

Include information for all medical professional who provide care or prescriptions for you, including family doctor, specialists, dentist, physical therapist etc.





Dr. Name Specialty Address Phone

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medical information

Allergies ______________________________________________________________________

Diagnosis ______________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Prescription Information

Pharmacy name and phone ______________________________________________

Medicine, dosage, how many pills, how many times a day (and what times), purpose. Don’t forget to include medications you don’t take on a regular basis (PRN)

Write each medication on a separate line (see below example)

Medication Dosage # of pills, how many times a day, time taken, reason

Tylenol 500 mg 2 pills twice daily 9 am 6 pm for back pain

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





____________________________________________________________________________________________________________________________________________________________

Other Important Information

Important names, addresses and phone numbers of family members, emergency contact or friends;

List by name, relation phone number

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Clergy ________________________________________________________________________

Attorney ______________________________________________________________________

Accountant ____________________________________________________________________

Funeral arrangements

Name and phone number of funeral home

____________________________________________________________________________

___________________________________________________________________________

Other Notes:

____________________________________________________________________________

___________________________________________________________________________




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