Patient Name _______________________________________________________________________
I will be away from ________________________________to_________________________________
Location___________________________________________ Phone __________________________

Diseases / ailments patient suffers from __________________________________________________
__________________________________________________________________________________

Symptoms _________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Allergies ___________________________________________________________________________

DOCTORS, MEDICAL CARE AND EMERGENCY CONTACTS
Primary care doctor __________________________________________________________________
Phone _______________________ Location _____________________________________________
Specialist doctor ____________________________________________________________________
Phone _______________________ Location _____________________________________________
Nearest hospital ____________________________________________________________________
Phone _______________________ Location ____________________________________________
Medical Insurance __________________________________________________________________

Friends and Relatives to contact in an emergency
Name/address____________________________________________ Phone____________________
Name/address____________________________________________ Phone____________________

MEDICATIONS
Medication Name Dose Time to give Special Instructions

APPOINTMENTS
(doctor's office, physical therapy, beauty/barber, visit friends, activities, etc. Include date, time, location,
contact name, phone number)
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________

ABOUT THE PATIENT
Patient's general emotional state (shy, weepy, sudden outbursts) _____________________________
_________________________________________________________________________________
Favorite distractions _________________________________________________________________
Dislikes___________________________________________________________________________

Moving the patient (circle those that apply)
Moves around unassisted 
Needs assistance transferring from to chair
Requires lift/wheelchair/walker 
Bedbound
Special moving instructions ______________________________________________________
Physical Therapies/ Exercises Needed ___________________________________________________
__________________________________________________________________________________

Toileting (circle those that apply)
Unassisted 
Catheter 
Colostomy
Bedside commode 
Bedpan 
Incontinent pads
Special instructions _____________________________________________________________
Sleep

Bed time _____________________ Wake time ______________________ Nap __________________

Meals (circle all that apply)
Eats unassisted 
Needs feeding assistance 
Needs to be fed
Has difficulty swallowing 
Eats soft foods only 
Tube feeding
Food allergies _______________________________________________________________________
Special eating instructions _____________________________________________________________
__________________________________________________________________________________

Entertainment
Patient enjoys (circle all that apply)
TV 
Radio 
Reading 
Being Read to 
Cards
Other ________________________________________________________________________
Avoid ________________________________________________________________________