Elder Care: INFORMATION COLLECTION WORKSHEET

Caring for an aging loved one can be very difficult. Which is why you should gather as much information as possible, right away. Having information you need at your fingertips can help make the daily challenges a little easier.

In addition to the checklist on this page, you can download this MS Word file, which will give you a simple document for recording importqant information. Remember, this is just a start. Be sure to consider what other information is important for your situation. Then save the document, and make at least one printout that you can keep easily at hand.

DOWNLOAD A MICROSOFT WORD FILE OF THE INFORMATION WORKSHEET HERE.

CHECKLIST:

Personal Information 

Date
Name
Age
Birthday
Social Security Number
Diagnoses
Address
Phone Number
Height                                                
Weight
Special Equipment / Devices
Allergies
Blood Type
Foods Not Allowed

Insurance & Medical Information 

Medicaid Number
Phone Number

Medicare Number
Phone Number

Primary Insurance & Number
Phone Number

Supplemental Insurance & Number
Phone Number

Medical Care Providers

Doctor
Address
Phone Number

Specialty Doctor(s)
Address
Phone Number

Hospital Affiliation
Address
Phone Number

Other Health Care or In-Home Care Provider
Phone Number
Current Medications & Dosage

Legal & Financial Information 

Location of important papers and documents
Will
Power of Attorney
Durable Medical Power of Attorney

Birth Certificate
Divorce Decree
Property Deeds
Safe Deposit Box
Location of Key (s)
Other Documents

Sources of Income

Monthly Income
Social Security
Retirement / Pension

Bank Accounts

Name of Bank
Account Number
Checking
Savings
Address
Phone Number

Investments

Institution or Broker
Phone Number
Location of Account Statements
Stocks
Bonds
Annuities
CDs
Mutual Funds
IRA’s
Money Market
Other

Accountant/Broker/Financial Planner 

Name
Address
Phone Number

Types of insurance 

Life
Disability
Long Term Care
ElderGap
Dental
Homeowners / Rental
Liability
Automobile

End of Life Information 

Funeral Pre-Planning
Funeral / Burial / Cremation / Memorial Arrangements
Clergy
Florist
Music / Songs
Newspaper / Obituary
People to be Contacted