Collecting Information Worksheet

Caring for an aging loved one can be very difficult, which is why you should gather as much of their information as is possible. Having information you need at your fingertips can help make caregiving challenges a little easier.

This Eldercare Information Collection Worksheet is a tool to help you get started. Remember to consider what other information is important for your situation. Download and print a few copies to keep on hand and possibly share with other family members or caregivers.

Eldercare Information Collection Worksheet

Download a PDF of the worksheet for your use. 

Personal Information

  • Name
  • Address
  • Phone numbers (cell, land line, other)
  • Birth Date (MM/DD/YY)
  • Height                                                 
  • Weight
  • Social Security Number
  • Diagnoses (if applicable)
  • Special Equipment/Devices (if needed)
  • Blood Type
  • Allergies or foods not allowed

Insurance and Medical Information

  • Medicare: ID Number and contact information
  • Primary Insurance: Company Name, ID Number, contact Information
  • Supplemental Insurance: Company Name, ID Number, Contact Information
  • Doctors: (Primary Care and Specialty Care) Name, address, contact Information
  • Dentist: Name/address/Contact Information
  • Additional Health Care or In-Home Care Providers: Name, address, contact Information
  • Hospital Affiliation: Name, address, contact Information
  • Current Medications and Dosage

Legal and Financial Information

  • Attorney name, address, contact information (if applicable)
  • Tax Accountant name, address, contact information (if applicable)
  • Financial Planner name, address, contact information (if applicable)
  • Location of important papers and documents such as a Will or Trust
  • Financial Power of Attorney: name, address, contact information (if applicable)
  • Durable Medical Power of Attorney: name, address, contact information (if applicable)
  • Birth Certificate and/or Passport
  • Divorce Decree (if applicable)
  • Property Deeds (if applicable)
  • Name change information (if applicable)
  • Social Security Account information
  • Retirement Account information
  • Pension (if applicable)
  • Additional Sources of Income: name, address, contact information
  • Passwords and account information for on-line accounts

Bank Accounts

  • Name of Bank(s), addresses, contact information
  • Account Numbers: (checking, saving, other)
  • Passwords and account information for on-line accounts
  • On-Line Banking information
  • Auto pay information

Investments

  • Institution, Broker or Financial Planner name, address, contact information
  • Location of investment account statements and ID numbers
  • Passwords and account information for on-line accounts
  • Stocks
  • Bonds
  • Annuities
  • CDs
  •  Mutual Funds
  • IRA’s
  • Money Market

Types of Insurance

  • Whole Life, Term Life, Long Term Care
  • Homeowners, Rental, Umbrella, specialty policies
  • Auto Insurance

End of Life Information

  • Hospice or Palliative Care (name, address, contact information)
  • Funeral Pre-Planning (if applicable)
  • Funeral, Burial, Cremation, Memorial Arrangements
  • Clergy
  • Florist
  • Music or Songs
  • Online or print Obituary
  • People to be contacted (name, address, contact information)