How to use this form
Completed by family / authorized contact — kept in caregiver's records
1. Client Information
Client full name
Date of birth
Home address
Preferred language
Insurance provider
Insurance ID / Member #
2. Physicians & Specialists
Primary physician
Primary physician phone
Specialist (type & name)
Specialist phone
Preferred pharmacy
Pharmacy phone
3. Emergency Contacts
Primary Contact
Name & relationship
Phone
Secondary Contact
Name & relationship
Phone
Healthcare Proxy / POA (if different)
Name & relationship
Phone
Document on file?
Preferred Hospital
Hospital name
City / address
Any notes for 911
4. Medical History
Current diagnoses & conditions
Past surgeries & hospitalizations (include approximate year)
Relevant family medical history
5. Current Medications
For reminders only. Caregiver does not administer medications.
| Medication Name | Dose | When to Take | Purpose | Prescribing Doctor |
|---|
6. Allergies & Adverse Reactions
| Allergen (medication, food, other) | Reaction | Severity |
|---|
7. Functional & Sensory Status
Vision
Hearing
Speech / communication
Chronic pain — location, level (1–10), and how it is managed
8. Mental Health
Diagnosed conditions (check all that apply)
Current treatment / management
9. Advance Directives
Additional notes on advance directives
10. Additional Notes
Completed By
Family / Authorized Contact Signature
Printed name
Relationship to client
Date
Caregiver Signature — received and reviewed
Date