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Organize Your Personal Health
This is a simply one page form, that you can copy as
much as you want. Once you fill this form out, take
it with you to your visits with your doctors. Keep it
updated. Place one copy near each phone.
See
Form
Recognize Risk Factors to Prevent Personal Injury
This basic one page handout identifies risk factors,
explains what part of the anatomy risk factors can harm,
and identifies a few ergonomic risk factors.
See
Form
Medicine Record
Our form designed
to help you keep an up-to-date, written list of all of the medicines
(prescription and over-the-counter) and dietary supplements,
including vitamins and herbals, that you use.
See
Checklist
Emergency Phone Numbers
Use this form to write all your important
numbers down. Be sure to make a copy to keep by each phone in your
home. See Form
Record Your Plans and Solutions
Use our one page planning worksheet to determine your
problems and goals, and make a plan for a solution.
See Form
Bladder Control Diary
Use this form to track your medication usage, medical
history, and give some suggestions for questions to ask
your doctor when dealing with bladder control issues.
Show your completed form to your doctor upon your visit.
See Form
General Home Safety Checklist for Dementia
Aging at home has many benefits, especially for people
with dementia who are easily confused by new and
unfamiliar settings. Since the home can also be a
potentially dangerous place for this population, basic
safety precautions should be implemented.
See Checklist
Questions About Abuse to Routinely Ask Mature
Adults
These questions are useful for any service provider
working with older adults, or family members to ask when
involved with vulnerable mature adults.
See article
Indicators of Possible Elder Mistreatment, Abuse,
Neglect or Exploitation
These descriptions are not necessarily proof of abuse,
mistreatment, neglect, or exploitation. But they may be
clues that a problem exists, or that counseling needs to
be offered or a report needs to be made to law
enforcement or Adult Protective Services (APS).
See Checklist
Coping With Cognitive Changes
You can take personal
control of your situation and choose new ways to cope
with changes.
See Tips to Cope With Cognitive Changes
Medical Practitioners
Definitions of medical practitioners.
See Glossary
Know What You Want to
Accomplish
Use this form to list your goals and your plan of
action.
See
Form
What is Your Role?
Use this form to organize your role as a caregiver.
See Form
Prevention Charts - How to Keep Track of Your
Healthcare
These charts can make it easier to keep track of your
health. Ask your doctor or nurse how often you need each
type of care and when. Then write down the information
in the charts here. Also, write down the date and
results of the care you get or ask your doctor to write
down this information.
See charts
Keep It With You Personal Medical Information Form
The Center for Disease Control now recommends carrying a
"Keep It With You : Personal Medical Information" form
during disasters and similar situations. In an emergency
situation, people may not be able to get to their
medical records. The “Keep It With You” (KIWY)
Personal Medical Information Form is intended to
be a voluntary and temporary record that lists medical
care and other health information for people who need
care during disasters and similar situations.
CDC says it is important for health care workers to
have a simple and reliable way to learn information
about past and new health concerns for people receiving
help.
View the form in PDF
They suggest writing in pencil so you can easily
change the info, folding the form and carrying it in a
plastic bag.
For more options, check out
MEDIC TAG. You can
include so much more important information. Change it
whenever you need to, carry on your key ring or wear on
lanyard.
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