307125
Waverley
OaksStreet,
Road Suite
205 Waltham,
MA02472
02452
Walnut
Watertown,
MA
617-926-4100 www.springwell.com
Dear Caregiver,
Welcome to the Springwell Caregivers Notebook!
The goal of this Notebook is to have a central place for you to record and
document the important aspects of your loved ones care. This includes:
Notebook Contents
Section 1 - At A Glance
Critical Information
Emergency Room Checklist
Person(s) able to make Legal, Financial & Medical decisions in Elders Stead
Home Emergency Information
Important Personal Contacts
Monthly Schedule Tracking Calendar
Section 2 - Care Providers
Caregiver Information
Professional Service Providers
About the Elder
Elders Self Care Abilities and Needs
Daily Activity Log
Section 3 - Medical
Medication and Pharmacy Information
Health Log
Medical Information
Important Medical Events
Important Tests
Physicians and Specialists
Section 4 - Call Log/Visit Notes
Call Log
Upcoming Doctor Visit Notes
Section 5 - Legal, Financial and End of Life Important Information
Location of Key Documents and Important Papers
Legal, Investment and Accounting Contacts
Insurance (non-medical) Information and Contacts
Banking Information
Income, Expenses and Net Worth
Monthly and Quarterly Bills
End of Life Instructions
Resources and Notes
Resources
Notes
Critical Information
Name
Date of Birth
Address
Phone
Emergency Contact
Name
Relationship
Contact Instructions
Home Ph
Work Ph
Cell Ph
Known Allergies
Medications
Food
Dietary Restrictions
Blood Sugar
Weight
Blood Type
Medical Care
Primary Care Doctor
Phone #
Hospital
Phone #
Specialty Doctor
Phone #
Health Insurance
Primary Plan
Supplemental
ID/Subscriber #
ID/Subscriber #
Phone #
Phone #
Location
Relationship
Work
Cell
Name
Relationship
Home #
Work #
Cell #
Name
Relationship
Home #
Work #
Cell #
Name
Relationship
Home #
Work #
Cell #
Services to suspend/cancel:
Telephone # and/or Website
Newspaper
Mail delivery
Meal/Food delivery
In Home Services
Cleaning
Home Health Care
Other:
Other:
Note: Check calendar to see if there are appointments that need to be canceled
Name:
Date of Birth:
Person(s) able to make Medical, Legal and Financial Decisions in Elders Stead
Health Care Proxy/Agent
Person authorized to make decisions on medical treatment in the event of mental incapacity
Name
Relationship
Address
Apt/Unit #
State
Zip Code
City
Home #
Work #
Email address
Cell #
Contact Instructions
Document on file with Physician (s):
Phone #
Name
Name
Phone #
Physician signed Do Not Resuscitate (DNR) Order on File?
Yes
No
DNR Order states there be no medical intervention to restore cardiac or respiratory function should either fail.
Durable? Yes
No
POA Legal authorization to handle the personal and financial affairs of another.
Durable POA- Remains in effect in the event of mental incapacity.
Name
Address
City
Home #
Cell #
Contact Instructions
Document location
Relationship
Apt/Unit #
State
Zip Code
Work #
Email address
Name
Address
City
Home #
Cell #
Contact Instructions
Document on file with
Relationship
Apt/Unit #
State
Zip Code
Work #
Email address
Guardian
Court appointed person to handle the personal and financial matters of one deemed mentally incompetent.
Name
Address
City
Home #
Cell #
Contact Instructions
Document on file with
Relationship
Apt/Unit #
State
Zip Code
Work #
Email address
Name:
Date of Birth:
Apt#
Phone #
Landlord
Phone #
Property Manager
Phone #
Emergency Contact
Phone #
Neighbor
Phone #
Police
Fire
Ambulance
Flashlight
Alarm Company
Code Clue
Special Instructions
Circuit Breaker/Fuse Box Location
Water Valve Shut Off
Home Maintenance
Plumber
Phone #
Electrician
Phone #
A/C Heating
Phone #
Handy/Repair Person
Phone #
Snow Removal
Phone #
Gardener/Landscaper
Phone #
Other
Phone #
Service
Electric
Company Name
Utility Companies
Phone #
Account #
Gas/Propane
Oil
Telephone
Cable/Internet
Other
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
2008 Springwell, Inc. All Rights Reserved.
Name:
Date of Birth:
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Name
Relationship
Address
City, State & Zip
Home #
Work #
Cell #
Email
Month
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Notes/To Do
Name:
Date of Birth:
Caregiver Information
Primary Caregiver
Name
Relationship
Address
Home #
Work #
Cell #
Email
Visits via
Frequency of visits
Assistance Provided:
Personal Care
Medication
Set up
Prompting
Meal Prep.
Breakfast Lunch
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
In Person
Phone
Assistance Provided:
Personal Care
Medication
Set up
Prompting
Meal Prep.
Breakfast Lunch
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
Phone
Phone
Religious/Cultural Organization
Name
Address
Phone
Frequency of visits
Assistance provided
Phone
Administration
Dinner
Assistance Provided:
Personal Care
Medication
Set up
Prompting
Meal Prep.
Breakfast Lunch
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
In Person
Administration
Dinner
Assistance Provided:
Personal Care
Medication
Set up
Prompting
Meal Prep.
Breakfast Lunch
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
In Person
Administration
Dinner
Administration
Dinner
Contact
Visits In Person
By Phone
Name:
Date of Birth:
Relationship
Work #
Cell #
Email
Visits via
How Often
In Person
Phone
Email
Name:
Date of Birth:
www.
Address
Phone #
Contact
Days/Hrs
Service
Frequency
Days/Times
Name
Paid for By
Start Date
End Date
Start Date
End Date
www.
Address
Phone #
Contact
Days/Hrs
Service
Frequency
Days/Times
Name
Paid for By
Other Providers (Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)
Agency Name
www.
Address
Phone #
Contact
Service
Frequency
Days/Times
Name
Agency Name
Paid for By
Start Date
End Date
Start Date
End Date
www.
Address
Phone #
Service
Contact
Frequency
Days/Times
Name
Paid for By
Name:
Date of Birth:
Other Providers (Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)
Agency Name
www.
Address
Phone #
Contact
Service
Frequency
Days/Times
Name
Agency Name
Paid for By
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
www.
Address
Phone #
Contact
Service
Frequency
Days/Times
Name
Agency Name
Paid for By
www.
Address
Phone #
Contact
Service
Frequency
Days/Times
Name
Agency Name
Paid for By
www.
Address
Phone #
Contact
Service
Frequency
Days/Times
Name
Agency Name
Paid for By
www.
Address
Phone #
Service
Contact
Frequency
Days/Times
Name
Paid for By
Name:
Date of Birth:
Pet(s)
Name
Feeding Instructions
Special Instructions
Name:
Date of Birth:
Personal Care
Independent
Bathing
Dressing
Grooming (hair, teeth)
Eating
Walking/Mobility
Toileting
Medications
w/Assistance (Describe)
Unable
Household Management
Independent
Meal Preparation
Food Shopping
Light Housework
Laundry
Transportation
Mail
Bill/Money Management
w/Assistance (Describe)
Unable
Adaptive Devices/Equipment
Item
Description
Glasses
Hearing Aid
False Teeth/Bridge
Arm Brace
Leg Brace
Orthodic
Cane
Walker
Wheelchair
Other
Other
Left
Right
Partial Upper Lower
Left
Right
Left
Right
Inserts Shoes
Straight
Pronged
w/ or w/o wheels
Standard
Electric
Notes
Name:
Date of Birth:
Breakfast
Morning
Lunch
Afternoon
Dinner
Evening
Name:
Date of Birth:
Form
Pill
Dosage
1 50 mg 2x/day
For
Allergies
Began
1/1/97
End
Notes
Take with food
Pharmacy
Address
City
Phone
Fax
Days/Hours
Website
Login ID
Password
Allergy Information
Drug
Reaction
First Occurred
Treatment
Name:
Date of Birth:
Health Log
Date
Time
Weight
Blood Pressure
Blood Sugar
Notes
Name:
Date of Birth:
Medical Information
Medical Diagnoses
Diagnosis
Date given
Doctor
Treatment/Status
Hospital
Complications, if any
Discharge Date
Discharged To
Name:
Date
Date of Birth:
Important Medical Events (heart attack, seizure, fall, surgery, ER/Hospitalization, Rehab stay, etc.)
Event
Treating Physician Hospital/Facility Admitted
Reason
Discharged
Notes
Name:
Date of Birth:
Description
Ordered By
Phone #
Test Results
Results kept
Name
Date of Birth
Physicians
Primary Care
Name
Address
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Name
Date of Birth
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Specialty Physician
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Specialty Physician
Start Date
End Date
Name
Specialty
Hospital/Clinic
Phone #
Pager #
Days/Hrs
Fax #
Email Address
Name
Date of Birth
Fax #
Days/Hrs
Pager #
Web/Email Address
Name
Address
Phone #
Fax #
Days/Hrs
Pager #
Web/Email Address
Name
Address
Phone #
Fax #
Days/Hrs
Pager #
Web/Email Address
Name
Address
Phone #
Fax #
Days/Hrs
Pager #
Web/Email Address
Name
Address
Phone #
Fax #
Days/Hrs
Pager #
Web/Email Address
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
2008 Springwell, Inc. All Rights Reserved
Name:
Date of Birth:
Call Log
Date/Time Notes = Spoke with, Agency Name, Phone#, What was discussed
To Do?
Name:
Date of Birth:
Time
Doctors Name
Specialty
Office/Clinic Location
Phone
Tests Done
Treatment
Scheduled for
What to Expect
Medication Changes
Remember to bring
Other Notes:
Above notes written by
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
2008 Springwell, Inc. All Rights Reserved.
Name:
Date of Birth:
Location
Date Noted
Annuity Contracts
Stock Certificates/Bonds
Date
Date
Name:
Date of Birth:
www.
City
Cell Phone
Assistants name
Financial Advisor/Planner
Name
Firm Name
Address
Office Phone
Email
Office Hours
www.
City
Cell Phone
Assistants name
Accountant/Tax Advisor
Name
Firm Name
Address
Office Phone
Email
Office Hours
Other
Name
Firm Name
Address
Office Phone
Email
Office Hours
www.
City
Cell Phone
Assistants name
www.
City
Cell Phone
Assistants name
www.
City
Cell Phone
Assistants name
State
Zip
State
Zip
State
Zip
State
Zip
State
Zip
Name:
Date of Birth:
Insurance
Home
Policy#
Agent Name
Agency Name
Address
Insurance Company/Underwriter
24 Hour Claim Phone #
Automobile
Car 1 Make
Policy#
Agent Name
Agency Name
Address
Insurance Company/Underwriter
24 Hour Claim Phone #
Car 2 Make
Policy#
Agent Name
Agency Name
Address
Insurance Company/Underwriter
24 Hour Claim Phone #
Phone #
www.
City
State
Zip
State
Zip
State
Zip
State
Zip
State
Zip
State
Zip
www.
Model
Year
Phone #
www.
City
www.
Model
Year
Phone #
www.
City
www.
Life
Policy#
Agent Name
Agency Name
Address
Insurance Company/Underwriter
24 Hour Claim Phone #
Phone #
www.
City
Disability
Policy#
Agent Name
Agency Name
Address
Insurance Company/Underwriter
24 Hour Claim Phone #
Phone #
www.
City
Phone #
www.
City
www.
www.
www.
Name:
Date of Birth:
Bank Name
Address
Phone
Contact Person
Email address
Checking Account #
Savings Account #
Money Market Account #
On Line Banking Website
Certificates of Deposit
Term
Amount
Bank Name
Address
Phone
Contact Person
Email address
Checking Account #
Savings Account #
Money Market Account #
On Line Banking Website
Certificates of Deposit
Term
Amount
www.
City
State
Zip
Branch where Acct was opened
Direct line
Branch Days/Hours
Addl Name on Acct
Addl Name on Acct
Addl Name on Acct
UserID
Password Clue
Start Date
Maturity Date
www.
City
State
Zip
Branch where Acct was opened
Direct line
Branch Days/Hours
Addl Name on Acct
Addl Name on Acct
Addl Name on Acct
UserID
Password Clue
Start Date
Maturity Date
www.
City
State
Zip
Branch where Acct was opened
Direct line
Branch Days/Hours
Addl Name on Acct
Addl Name on Acct
Addl Name on Acct
UserID
Password Clue
Start Date
Maturity Date
Name:
Date of Birth:
$
$
$
$
$
$
$
$
$
Assets (own)
Checking Account
Savings Account
CDs
Money Market Funds
Life Insurance (cash value)
Approximate Market Value of
Pension Funds
Mutual Funds
Stocks
U.S Treasury (bills, bonds)
Real Estate Equity
Automobiles
Personal (Jewelry, Art, Furniture)
Other (boat, etc)
Other
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Expenses
Rent/Mortgage
Other Mortgage
Bank Loan
Income Tax (Qtrly)
Property Tax
Utilities
Phone
Gas
Oil
Electric
Water
Cable
Groceries
Restaurants
Personal (hair, clothes)
Auto (gas, repair)
Other Transportation
Medical
Dental
House (landscaper, etc)
In Home Services
Other
Other
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Liabilities (owe)
Mortgage
Second Mortgage
Reverse Mortgage
Bank Loans
Car Loans
Credit Cards
Personal Loans
Other
TOTAL
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total Assets
Minus Total Liabilities
Total Assets
$
Minus Total Liabilities $
NET WORTH
$
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
2008 Springwell, Inc. All Rights Reserved.
Name:
Date of Birth:
Monthly Bills
Expense
Rent/Mortgage
Other Mortgage
Bank Loan
Credit Card
Credit Card
Credit Card
Credit Card
Gas/Auto Credit Card
Gas (house)
Oil
Electric
Phone
Cellular Phone
Trash Collection
Cable/Internet
Newspaper
Other
Other
Name
Account #
Phone #
Due Date
Phone #
Due Date
Notes
Quarterly Bills
Expense
Property Tax
Estimated Income Tax
Water
Other
Other
Name
Account #
Notes
Name:
Date of Birth:
Do Not Hospitalize
Do Not Resuscitate (revive heart or breathing)
Do Not Tube Feed (insertion of tube into stomach to provide nutrition) Do Not Intubate(insertion of a tube to assist breathing)
No Extraordinary Measures (any effort to artificially sustain life when no hope of medical improvement exists)
Comfort Measures Only (no intervention to prevent death and make physically as comfortable as possible)
Relationship
Work #
Cell #
Relationship
Work #
Cell #
Relationship
Work #
Cell #
Relationship
Work #
Cell #
Attorney to be notified
Name
Address
Phone #
Firm Name
City
Cell #
Clergy to be notified
Name
Address
Phone #
City
Funeral Home
Address
Phone #
Cemetery
Address
Phone #
State
Zip
State
Zip
City
Pre-Paid
State
Zip
City
Pre-Paid Lot#
State
Zip
Other instructions
Resources
Springwell, Inc.
125
Walnut Street
307 Waverley
Oaks Road Suite 205
Waltham, MAMA
02452
Watertown
02472
617-926-4100
TTY: 617-923-1562
Fax: 617-926-9897
www.springwell.com
inforef@springwell.com
Medicare
http://www.medicare.gov/
800-633-4227
Medicaid - MassHealth
www.mass.gov/masshealth
800-841-2900
Social Security Administration
http://www.ssa.gov/
800-772-1213
Notes
Springwell, Inc.
125Waverley
Walnut Street
307
Oaks Road Suite 205
Waltham,
MA
02452
Watertown MA
02472
617-926-4100
TTY: 617-923-1562
Fax: 617-926-9897
www.springwell.com
inforef@springwell.com