You can fill in your loved one’s information from your computer using the form fields provided, or you can print it out and fill it out by hand.
General medical information
Use this form to jot down your loved one’s important details, like his or her address, phone number, and insurance information. Make sure to include other details that could be important in case of emergency, such as medical conditions, allergies, and dietary restrictions.
What to do in an emergency
Make a detailed list of all of your loved one’s emergency contact information. Suggestions for how to handle emergencies can also be included.
Health care providers
Record the contact information for all of your loved one’s medical providers, pharmacies, and preferred medical facilities.
What the doctor needs to know
Create a list of names and phone numbers of doctors. Don’t forget to include physical therapists, nutritionists, or other specialists the person in your care may see. If multiple people are managing his or her care, create a copy of the list for everyone to keep on hand.
Prescription and over-the-counter medicines
Use this form to jot down the details of any prescription or over-the-counter medicines your loved one is using, and the health condition for which they are used.
Vitamins, supplements, and herbals
Write down the names of any vitamins, supplements, or herbals that your loved one is taking and the health condition for which they were prescribed. If he or she stops taking a vitamin, supplement, or herbal, simply write down the reason in the space provided.
Keep your loved one’s driver’s license and insurance information easily available. Make sure to also record where important documents are stored, like insurance forms, wills and trusts, advanced directives, and do-not-resuscitate paperwork.
Use this form to jot down the details of routines, limitations, and needs of the person in your care.
Medical costs tracker
Account for your loved one’s expenses, recording the date and type of service, the total bill, and the out-of-pocket costs.
This space can be used to record any additional information you may need.