General Needs Assessment

Home Maintenance and Living Situation

____ Pay rent/mortgage

____ Home repairs

____ Ongoing maintenance

____ Safety concerns

____ Accessibility for disabilities

____ Grocery shopping & meal preparation

____ Lawn care

____ Pet care

____ Housekeeping

____ Other: ________________________

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

Financial Affairs

____ Paying bills

____ Keeping track of financial records

____ Supervising public benefits programs, etc.

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

Transportation Needs

____ Driving decisions

____ Coordinating rides

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

Personal Care

____ Organization of family and professional care providers

____ Rides to hair stylist

____ Help with bathing Health Care

____ Make, accompany, drive or make alternate logistic arrangements for doctor’s appointments

____ Submit medical insurance and bills

____ Explain medical decisions

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

Communications

____ Keeping family caregiving team informed

____ Coordinating visits

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

Adaptive Devices

____ Ordering, maintaining, and paying for adaptive devices (e.g., wheelchair, walker, etc.)

APPOINTED FAMILY MEMBER:

ADDRESS:

PHONE:

EMAIL:

PERSONAL INFORMATION CHECKLIST & WHERE IS IT KEPT

___Birth Certificate

___Marriage Certificate

___Death Certificate (for Deceased Spouse)

___Divorce Papers

___Military Records

___Branch of Service:

___VA ID#:

___Veterans Military Service Record

___Dates of Service:

___Driver’s License/Organ Donor Card

___Passport/Citizenship Papers

___Will

___Trusts

___Durable Power of Attorney for Health Care

___Medicare Number & Identification Card

___Medicare Savings Program? Y N

___Medicaid Number & Identification Card

___Medicare Prescription Drug Coverage Extra Help Program? Y N

____Health Insurance Policy: Premium:

___Do Not Resuscitate (DNR) Order

___Advance Directive

___Life Insurance Policy

___Disability Insurance (long- and short-term)

___Long-Term Care Insurance

___Safety Deposit Box(es)

___Address Books (names & addresses of friends & colleagues)

___Lists of church & community memberships & contact information

___Information on waiting lists or contracts with retirement communities or nursing homes

___Information on cemetery plots and funeral & burial instructions

___Plan for care of family pets

___Mortgage or Rental Documents & Bills

___Real Estate Agent:

___Utility Bills Power Company:

___Gas Company:

___Cable/Internet:

___Low Income Home Energy Assistance (LIHEAP) Y N

___Telephone Bills

___Telephone Companies:

___Low-Income Assistance? Y N

___Homeowners Insurance Policy

___Insurance Agent:

___Homeowners Insurance

___PHARMACY PHONE # & ADDRESS

___DOCTOR PHONE # & ADDRESS

___List of Prescriptions & Dosage & Cost

___Auto(s):

___Auto Loan Information

___Title for Car(s)

___Title for Recreational Vehicle(s)

___Car Insurance

___Public Transportation Options

___Make(s): Model(s):

___Blue Book Value of Car(s):

___Insurance Company:

___Bank Records (checking/savings accounts)

___Any rental agreements or business contracts

___Complete list of assets & debts

___List of routine household bills

___Federal & State Tax Returns (past 3-5 years)

___Records of any personal loans made to others

___ Security Income (SSI)

• For more information, go to www.aarp.org.

Sources: www.aarp.org