Planning Checklist for Caregiving Families Part 1
Personal History
Name (First Middle Last):
Name at birth (First Middle Last):
Place of birth (City State Country):
Date of birth: Date of adoption:
Legal name change (First Middle Last):
Legal name change date: Legal name change court:
Court City State:
Current address:
# of years:
Phone: Cell phone:
Email: Email:
Blood type: Organ/tissue donor: ❑ Yes ❑ No
Citizenship: ❑ By birth ❑ By naturalization
Naturalization date:
Naturalization place (City State Country):
Military veteran: ❑ Yes ❑ No Branch of service:
Dates of service: Serial #:
Rank: Type of discharge:
Social Security #: Passport #:
Expiration: Country of issue:
Driver’s license #: Expiration:
State identification card #: State of issue:
Registered to vote at precinct: County:
State:
Faith/Denomination: Place of worship:
Address: Pastor/Priest/Rabbi/Spiritual leader:
Phone #: Email:
Marital Status: ❑ Divorced ❑ Married ❑ Never married ❑ Widowed
First Spouse
Name of spouse:
Date of birth: Place of birth:
Date of marriage: Date of divorce:
Date of death:
Spouse is buried at:
Phone:
Email:
Address:
Second Spouse
Name of spouse:
Date of birth: Place of birth:
Date of marriage: Date of divorce:
Date of death:
Spouse is buried at:
Phone:
Email:
Address:
Children
Name of first child:
Phone:
Email:
Address:
Name of spouse:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of second child:
Phone:
Email:
Address:
Name of spouse:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of third child:
Phone:
Email:
Address:
Name of spouse:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Name of grandchild:
Phone:
Email:
Address:
Personality:
Values:
Religious beliefs or practices:
Skills and talents:
Short-term goals:
Long-term goals:
Interests and activities:
Special likes:
Special dislikes:
Activity Levels
Get in and out of shower/tub- Independent, Needs Some Help, Needs Help
Shave- Independent, Needs Some Help, Needs Help
Wash hair- Independent, Needs Some Help, Needs Help
Style hair- Independent, Needs Some Help, Needs Help
Dress- Independent, Needs Some Help, Needs Help
Brush teeth- Independent, Needs Some Help, Needs Help
Trim fingernails- Independent, Needs Some Help, Needs Help
Trim toenails- Independent, Needs Some Help, Needs Help
Toilet Control- Independent, Needs Some Help, Needs Help
Manage incontinence- Independent, Needs Some Help, Needs Help
Prepare meals- Independent, Needs Some Help, Needs Help
Grocery shop- Independent, Needs Some Help, Needs Help
Feed self- Independent, Needs Some Help, Needs Help
Select appropriate foods- Independent, Needs Some Help, Needs Help
Chew- Independent, Needs Some Help, Needs Help
Swallow- Independent, Needs Some Help, Needs Help
Make medical appointments- Independent, Needs Some Help, Needs Help
Get to appointments- Independent, Needs Some Help, Needs Help
Schedule tests- Independent, Needs Some Help, Needs Help
Follow doctor’s instructions- Independent, Needs Some Help, Needs Help
Take medications on time/correct dosage- Independent, Needs Some Help, Needs Help
React to an emergency- Independent, Needs Some Help, Needs Help
Communicate needs- Independent, Needs Some Help, Needs Help
Get into/out of a chair- Independent, Needs Some Help, Needs Help
Get into/out of a bed- Independent, Needs Some Help, Needs Help
Drive- Independent, Needs Some Help, Needs Help
Use public transportation- Independent, Needs Some Help, Needs Help
Do household chores- Independent, Needs Some Help, Needs Help
Use checkbook- Independent, Needs Some Help, Needs Help
Use ATM- Independent, Needs Some Help, Needs Help
Manage personal expenses- Independent, Needs Some Help, Needs Help
Manage investments- Independent, Needs Some Help, Needs Help
Use telephone- Independent, Needs Some Help, Needs Help
Use computer- Independent, Needs Some Help, Needs Help
Use personal emergency response unit- Independent, Needs Some Help, Needs Help
Take care of pets- Independent, Needs Some Help, Needs Help
Stay safe from falls- Independent, Needs Some Help, Needs Help
Signs of Difficulties Managing Finances
❑ I have observed the following difficulties managing finances:
❑ Unopened mail
❑ Late payment of bills
❑ Repeat payments of bills
❑ Unusual spending patterns
❑ Mounting credit card debt
❑ Calls from debt collection agencies
❑ Utility shutoff
❑ Foreclosure or eviction notice
❑ Confusion about how to interpret an invoice, statement, or letter
❑ Inability to write checks
❑ Difficulty balancing checking account
❑ Stress and confusion over paperwork
❑ Disorganization of paperwork
❑ Loss of ability to manage email or computer
❑ Excessive telemarketing callers
❑ Victimized by scammer
❑ Multiple payments to charities
❑ Trinkets and prizes
❑ Sweepstakes mail
Signs of Financial Exploitation
❑ I have observed the following signs of possible financial exploitation:
❑ Excessive telemarketing callers
❑ Multiple payments to charities
❑ Significant change in spending pattern
❑ Unusual activity in bank accounts
❑ Financial transactions that can’t be explained
❑ Use of credit card or ATM card by others
❑ Bank statements no longer being received
❑ Checks made out to cash
❑ Wire transfers to nonfamily members
❑ New “best friend”
❑ Exclusion from usual circle of friends or social activities
❑ Someone new making financial transactions or decisions
❑ Missing money or property
❑ Change in names on bank accounts, deeds
❑ Change in power of attorney or will
❑ Change in beneficiaries on life insurance, retirement accounts
❑ Suspicious signatures on checks or documents
• For more information, go to www.aarp.org.
Sources: www.aarp.org
