CAREGIVER’S CHECKLIST PERSONAL INFORMATION
HEALTH INFORMATION Medical Conditions
Name Address
Prescriptions/Dosage/Frequency
Home Phone/Cell Phone Numbers
Diabetes o Yes o No
Date of Birth/Birthplace
Insulin Dosage/Frequency
Driver’s License Number & State
Insulin Last Dose/Next Dose
Medicare Number & Effective Date
Dialysis o Yes o No Dialysis (Name of Facility)
Medicaid Number & Effective Date
Dialysis Last Treatment/Next Treatment
Case Worker’s Name
Allergies
Case Worker’s Phone Number
Surgeries
Health Insurance Provider
Medical Devices (Pacemaker/Pain Pump/Oxygen)
Health Insurance Address
Cardiac Bypass/Valve Replacement
Health Insurance Group Number
Transplant (Heart/Kidney/Liver/Lung)
Dental Insurance Provider
Joint Replacement
Dental Insurance Address
Primary Care Physician’s Name
Dental Insurance Group Number
Primary Care Physician’s Address/Phone Number
Vision Insurance Provider
Dentist’s Name
Vision Insurance Address
Dentist’s Address/Phone Number
Vision Insurance Group Number
Eye Doctor’s Name
Emergency Contact’s Name
Eye Doctor’s Address/Phone Number
Emergency Contact’s Address
Hearing Aid Provider
Emergency Contact’s Phone Number
Hearing Aid Provider’s Address/Phone Number
Emergency Contact’s Relationship to Patient
Dentures/Partial Bridges o Yes o No
Insulin Dependent o Yes o No
Eyeglasses/Contacts o Yes o No Hearing Aids o Yes o No Local Ambulance Phone Number