Care information sheet

Keep the basics in one place so a sibling, a sitter, or a hospital team can step in without guessing. You can download a full PDF, or a one-page fridge and emergency sheet. This stays on this device. It is not a medical or legal document.

Stays on this device only. Nothing is uploaded. Clear it when you are done if this is a shared computer.

Get started when you are ready. You can leave any line blank.

About them

Name they like to be called Full legal name Birthday Where they live (the area is enough if you would rather not write a full address) Diagnosis, in the words you use at home Languages they speak or understand The person who knows them best, and how to reach them

Health and medicines

Health conditions a doctor has named Allergies, or write “none known” Glasses, hearing aids, walker, or other devices

Medicines

Add each medicine, the dose, and when it is taken. You can remove a line if you added one by mistake.

Doctors and pharmacy

Pharmacy name Pharmacy phone Preferred hospital, if you have one

Insurance

Medicare or main insurance, and the member number if you want it here Supplement, Medicaid, or other coverage Where the insurance card is kept

Emergency contacts

List the people to call, in order, with a relationship and a phone number.

Legal papers and where they are kept

You do not need to write out wishes here. Just note whether a paper exists and where a copy can be found, including a health care power of attorney, a living will or advance directive, a financial power of attorney, a will, or a DNR or POLST if there is one.

Health care power of attorney, and where it is kept Living will or advance directive, and where it is kept Financial power of attorney, and where it is kept Will or trust, and where it is kept DNR, POLST, or other medical order, and where the signed copy is kept Other papers or a lawyer to call

Daily routine

Mornings, including getting up and breakfast Daytime, including meals, rest, and activities they expect Evenings and bedtime Eating and drinking, including foods they love or should avoid Personal care, such as bathing, dressing, or bathroom help Sleep, including what helps them rest

What calms them, and what upsets them

What helps if they are anxious or upset Things that may worry or upset them

Likes, interests, and people who matter

Favorite people, pets, music, shows, hobbies, or places Work, family, faith, or other parts of their story that help someone new know them

How to communicate

How they usually communicate, and what helps you understand them Hearing and eyesight, including glasses or hearing aids How they get around, and what help they need

A page for someone new in their care

Use this page when a new aide, a family member, or hospital staff is meeting them for the first time. Write it in a warm, everyday voice, as if you are introducing your loved one to a kind neighbor.

What I would like you to know first Please call me Please do this Please avoid this

This is for your records. It is not medical or legal advice. If you print the fridge sheet, put it in a clear sleeve on the refrigerator and tell family and any sitter where it is.

This is general information to help you get started. It is not legal, medical, or financial advice. Rules and benefits change. Check with your local agency, your doctor, or a trusted advisor before you decide.

How do I find help near me?

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