This form is written to stress the essential viewpoint of the aging adult.  The client and/or caregiver and family should complete it with as much direct input as possible from the client.  The completed form will be most helpful in preparing new people to work with the client and to ease transitions from one living situation into another.
 

Names

I prefer to be called: ______________________________________________________________

I like to call my caregiver: __________________________________________________________
 

Internal Clock

I start my day at ____________________________________________(time) and my first task
is______________________________________________________________, after which I like
to________________________________________________________________.

I end my day at________________________________________(time) and the last few things I
do are___________________________________________________________, after which I like
to______________________________________________________________, after which I like
to_____________________________________________________________.

My best time of day is____________________________________________________________.

My most difficult time of day is_____________________________________________________.
 

Eating and Drinking Preferences

My first meal of the day generally consists
of______________________________________________________________________. I never
eat_____________________________________________________________________, but I
can always go for________________________________________________________.

My beverage of choice is___________________________________________________________.

This changes depending on the time of day, so these are my other
choices_________________________________________________________________________.

I like my coffee or tea (circle one) prepared_____________________________________________.

I like to eat my meals in this room:___________________________________________________.

I prefer you (my caregiver) to eat with me - yes or no (circle one).

My favorite restaurant is___________________________________________________________.

Other food preferences or allergies:
 

Dressing / Grooming Preferences

I am most comfortable wearing_____________________________________________________.

If I go out on an appointment or errand, I like to wear:
_______________________________________________________________________________.

If I'm going to church/temple, I like to wear:
_______________________________________________________________________________.

I can help dress or groom myself by:
_______________________________________________________________________________.
______________________________________________________________________________.

I need assistance with:
_______________________________________________________________________________
_______________________________________________________________________________.
 

Getting Around

I am right handed or left handed (circle one).

The following are some things I have trouble doing:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

The following are some things I'm really good at doing:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

I use the following equipment to help me get around:
walker, cane, wheel-chair (circle one), or:_____________________________________________.

If you're transporting me to an appointment, I prefer a med/handicapped
vehicle service or a private car (circle one), or:_________________________________________.

Other comments about getting around:_______________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.
 

Eye Sight

I wear glasses - yes or no (circle one). I'm near or far sighted (circle one).

I wear them at the following times or during the following
activities:_______________________________________________________________________
_______________________________________________________________________________.

I keep my glasses (where):_________________________________________________________.

Due to my eyesight it helps if you____________________________________________________
________________________________________________________________________________
_______________________________________________________________________________.
 

Hearing

My hearing is good, fair, or poor (circle one).

I am better able to understand if you__________________________________________________
_______________________________________________________________________________.

I wear a hearing aide - yes or no (circle one).

I keep my hearing aide (where):______________________________________________________.

I require assistance with putting it in - yes or no (circle one).

The following person purchases batteries:_____________________________________________.
 

Favorite Activities or Hobbies

While at home, I like having music play - yes or no (circle one).

My favorite type of music is______________________________________________, my favorite
radio station is______________________________________________. I don't like the following
music_____________________________________________________.

My favorite television shows
are____________________________________________________ day / time:______________
_______________________________________________________ day / time:______________
_______________________________________________________ day / time:______________
_______________________________________________________ day / time:______________

The room of the house where I like to spend the majority of my time
is____________________________________________________________________________.

My favorite chair or sofa is_________________________________________________________.

I always like to have the following items readily
accessible_____________________________________________________________________
______________________________________________________________________________.

I like to read the following types of
books_________________________________________________________________________
_______________________________________________________________________________.

This person can get reading materials for me:_________________________________________.

I like you (my caregiver) to read out loud to me - yes or no (circle one).

Other things I enjoy doing:_________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________.

I am active in the following community
programs_______________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________.
 

Disposition

Caregivers often have difficulty getting me to___________________________________________
_______________________________________________________________________________.

I get agitated by__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

I calm down by___________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.
 

Special Requirements

I have Alzheimer's Disease or related diagnosis - yes or no (circle one).

I have little recollection of yesterday or my distant past (circle whichever is applicable).

I become easily confused - yes or no (circle one).

The following programming/activities help_____________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________.

When I am talking about events from the past as if they were happening in
the present, it is best to:__________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
 

Legal Aids and Decision Making Tools

I have a Durable Power of Attorney - yes or no (circle one).
Please attach copy to this booklet.

I have a Living Will - yes or no (circle one). Please attach copy to this booklet and ensure that your family and physician also have copies.

I have a Durable Power of Attorney for Health Care - yes or no (circle one).  Please attach copy to this booklet.
 

Finances: Payment Sources

I have Medicare Part A and/or Part B (circle all that apply). My Medicare
number is____________________________________________________________. I keep my
card_________________________________________________________________________.

I have another private insurance carrier - yes or no (circle one). Please
name all insurers and provide card numbers__________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.

I have Medical Assistance/Medicaid - yes or no (circle one). My card
number is______________________________________________________________________.
I keep my card__________________________________________________________________.