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The Caregivers Notebook

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125 Walnut Street, Watertown, MA 02472 617-926-4100 www.springwell.com
The Caregiver’s Notebook
A Guide for Organizing and Record Keeping
Print Form
307 Waverley Oaks Road Suite 205 Waltham, MA 02452
Questions? Call us at 617-926-4100 (TTY 617-923-1562) or visit us on the web:
www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Dear Caregiver,
Welcome to the Springwell Caregiver’s Notebook!
The goal of this Notebook is to have a central place for you to record and
document the important aspects of your loved one’s care. This includes:
• Critical At A Glance Information
• A Calendar for Schedule Tracking
• Care Providers
• Daily Routine and Care information
• Medication Information
• Health Information and Medical Events
• Medical Professional Contacts
Because it is easy to forget details from conversations and important next
steps, we have included a Call Log section for tracking telephone calls and
notes from medical appointments.
We have also included a section for legal, financial and insurance information.
Since this information is confidential, we suggest the section be removed and
stored in a safe place.
The Notebook is intended to be comprehensive. Some sections may not be
immediately relevant. As you fill it in, it will help you be prepared when the
need for the information arises.
Since information changes, use a pencil when filling out some of the forms
(e.g., Medications). For your convenience, extra copies of the forms are
available to download from our website, www.springwell.com.
Our telephone number and website is included on every page. Please call us
with your questions and concerns. We are here to help you on your caregiving
journey.
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Making the most of this Organizational Tool
There is no question that filling out each line in this book can feel overwhelming. Because it
was designed to be a launching point for being a better informed and organized Caregiver, it
covers a wide range of information and details. Keep in mind you don’t need to complete every
line in each section. Use this as your framework for gathering and organizing information.
Here are some tips on how to make the most of this Notebook:
• Pace yourself by choosing the pages and sections that are most relevant now, and start
there.
• As much as possible, involve your loved one in completing the information. It will
provide the opportunity for discussion and may also provide a sense of control during a
time when control may seem fleeting to them.
• As with caregiving, don’t ‘go it alone’. Enlist family members and others close to the
elder to help complete a page or an entire section.
• Since this tool is a 3 ring binder, you can customize it. Rearrange the sections to fit your
organizational style. Decide which sections you want to have at the ready, which
sections should stay at the elder’s home and which sections should be removed to be
stored in a safe place.
• To make certain pages portable, we suggest removing and storing them in a separate
“travel” binder.
• Photocopy important papers to put into the binder while keeping the original in a safe
place.
• Use colored Post-It Note flags to alert a family member, friend or other caregiver on any
important changes or additions in the Notebook.
• Don’t limit the use of the Calendar to remembering medical appointments. Use it as a
tracking system for calls to make, medication changes, when a prescription needs to be
refilled, etc.
• Gathering financial information can be a daunting task. Collecting one month’s worth of
mail will give you a snapshot of existing bills and financial statements (except for those
that come quarterly). The most recent tax return is another good source of financial
information. Remember, it is always best to ask permission to access any type of
financial records.
• Most importantly, use the Springwell Caregiver Program as your caregiving resource. A
Caregiver Advisor can guide you on personalizing this tool to fit your caregiving needs.
If you need suggestions on how to gather important information or broach a subject with
a loved one, call us. A Caregiver Advisor is available to speak to in person as well as by
phone and email to provide you with information and resources.
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Notebook Contents
Section 1 - At A Glance
Critical Information
Emergency Room Checklist
Person(s) able to make Legal, Financial & Medical decisions in Elder’s Stead
Home Emergency Information
Important Personal Contacts
Monthly Schedule Tracking Calendar
Section 2 - Care Providers
Caregiver Information
Professional Service Providers
About the Elder
Elder’s 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
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Critical Information
Name Date of Birth
Address Phone
Emergency Contact Nearest Relative, Friend/Neighbor
Name Name
Relationship Relationship
Contact Instructions Contact Instructions
Home Ph Home Ph
Work Ph Work Ph
Cell Ph Cell Ph
Special Health/Medical Conditions and Instructions
Known Allergies
Medications Food
Dietary Restrictions Daily Fluid Intake
Baseline: Blood Pressure Blood Sugar Weight Blood Type
Medical Care
Primary Care Doctor Phone #
Hospital Phone #
Specialty Doctor Phone #
Health Insurance
Primary Plan ID/Subscriber # Phone #
Supplemental ID/Subscriber # Phone #
Declared Emergency Medical Instructions
Include the name and location of any written documentation of emergency care wishes. For example, Physician
signed Do Not Resuscitate (DNR) order, Health Care Proxy/Advanced Directive, or “File of Life”.
Document Name Location
Health Care Agent Relationship
Contact #’s: Home Work Cell
Other Important Information
Note anything an outsider should be aware of including information about hearing, vision, memory, balance,
walking, getting in/out of a chair or car, etc. If the elder has a Personal Emergency Response Service (i.e., Lifeline),
note where the activation button is located.
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Emergency Room Checklist
Items to bring with you:
Medical Insurance Cards
List of telephone and contact information on all doctors and health care providers (Primary Care,
Specialists, Home Health providers)
List of all medications including over the counter, prescriptions and any supplements
Assistive/Adaptive devices such as hearing aides, glasses, dentures, cane or walker
Comfortable clothing (ideally without metal fasteners/zippers in case MRI or CT is needed),
nightgown/pajamas, warm socks and slippers
List of telephone numbers of close family members, friends and neighbors
Other:
Notify (family members, neighbors, friends):
Name Name
Relationship Relationship
Home # Home #
Work # Work #
Cell # Cell #
Name Name
Relationship Relationship
Home # Home #
Work # Work #
Cell # 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:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Person(s) able to make Medical, Legal and Financial Decisions in Elder’s Stead
Health Care Proxy/Agent
Person authorized to make decisions on medical treatment in the event of mental incapacity
Name Relationship
Address Apt/Unit #
City State Zip Code
Home # Work #
Cell # Email address
Contact Instructions
Document on file with Physician (s):
Name Phone #
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.
Power of Attorney (POA) 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 Relationship
Address Apt/Unit #
City State Zip Code
Home # Work #
Cell # Email address
Contact Instructions
Document location
Conservator or Representative Payee
Conservator – Court appointed person to handle the financial affairs of one deemed mentally incompetent.
Representative Payee – Person authorized to receive an elder’s Social Security check for bill paying purposes.
Name Relationship
Address Apt/Unit #
City State Zip Code
Home # Work #
Cell # Email address
Contact Instructions
Document on file with
Guardian
Court appointed person to handle the personal and financial matters of one deemed mentally incompetent.
Name Relationship
Address Apt/Unit #
City State Zip Code
Home # Work #
Cell # Email address
Contact Instructions
Document on file with
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Home Emergency Information
Address Apt# Phone #
Landlord Phone #
Property Manager Phone #
Emergency Contact Phone #
Neighbor Phone #
Police Fire Ambulance
Fire Extinguisher Location 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 #
Utility Companies
Service Company Name Phone # Account #
Electric
Gas/Propane
Oil
Telephone
Cable/Internet
Other
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Important Personal Contacts
For important correspondence, list important personal contacts such as relatives, neighbors, and friends
(former classmates, co-workers, etc). “If something happened and you were in the hospital, who would you
want me to call?”
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
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Month
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Notes/To Do
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Caregiver Information
Primary Caregiver
Name
Relationship
Address
Home #
Work #
Cell #
Email
Visits via In Person Phone Email
Frequency of visits
Other Informal (unpaid) Caregivers
Name
Relationship
Address
Home #
Work #
Cell #
Email
Visits via In Person Phone Email
Frequency of visits
Name
Relationship
Address
Home #
Work #
Cell #
Email
Visits via In Person Phone Email
Frequency of visits
Name
Relationship
Address
Home #
Work #
Cell #
Email
Visits via In Person Phone Email
Frequency of visits
Religious/Cultural Organization
Name
Address
Phone Contact
Frequency of visits Visits
In Person
By Phone
Assistance provided
Assistance Provided:
Personal Care
Medication Set up Prompting Administration
Meal Prep. Breakfast Lunch Dinner
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
Assistance Provided:
Personal Care
Medication Set up Prompting Administration
Meal Prep. Breakfast Lunch Dinner
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
Assistance Provided:
Personal Care
Medication Set up Prompting Administration
Meal Prep. Breakfast Lunch Dinner
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
Assistance Provided:
Personal Care
Medication Set up Prompting Administration
Meal Prep. Breakfast Lunch Dinner
Shopping
Transportation
Medical Appointments
Bill Paying/Money Management
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Detailed Caregiver Information
Name Relationship
Address
Home #
Work #
Cell #
Contact Instructions
E
mail
Visits via How Often
In Person
Phone
Email
Type of Assistance Provided
Personal Care Frequency of Assistance/Notes
Bathing
Dressing
Grooming (hair, teeth)
Walking/Mobility
Lifting/Transferring
Toileting
Eating
Medications
Setting up pill box
Prompting to take
Helping to take
Household Management
Meal Preparation
Food Shopping
Light Housework
Laundry
Personal Management
Transportation
Shopping/Errands
Medical Appointments
Mail/Correspondence
Banking/Bill Payment
Home Management
Fix It/Repair
Lawn Care
Snow Removal
Automobile Care
Other Assistance
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Professional Service Providers
Skilled Nursing and Rehabilitation (Physical, Speech, Occupational) Therapies
Agency Name www.
Address
Phone # Contact
Days/Hrs After Hours Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Personal Care and Homemaking Services
Agency Name www.
Address
Phone # Contact
Days/Hrs After Hours Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Other Providers
(Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Other Providers
(Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Agency Name www.
Address
Phone # Contact
Service Frequency Days/Times Name Paid for By Start Date End Date
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
About the Elder
The following is to help an outside caregiver learn about your loved one’s likes, dislikes and important
information about their life and day-to-day activities.
Prefers to be called (Mr/Mrs/Miss, Nickname)
First Language Other languages spoken
Important Social History (schooling, career, membership organizations, etc.)
Important Relationships (close relatives and friends)
Name Relationship Town Type and Frequency of contact
Enjoys spending time by (social activities, etc.)
Favorite places to go (restaurants, museums, parks, etc.)
Favorite Pastimes (be as specific as possible and attach additional pages if necessary)
Hobbies Games Songs/Music TV Shows Radio Station
Topics of interest (current events, sports, history, etc.)
Food & Snack preferences and dislikes
Pet(s) Name Feeding Instructions Special Instructions
Daily Routine Overview
Wakes up at
Breakfast
Morning Routine
Lunch
Afternoon Routine
Dinner
Before Bed
Bedtime
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Elder’s Self-Care Abilities & Needs
Date
As you fill this out, think about whether you are comfortable with your loved one seeing your assessment of
their abilities. If not, consider using it as an opportunity to discuss your concerns with them.
Personal Care
Independent w/Assistance (Describe) Unable
Bathing
Dressing
Grooming (hair, teeth)
Eating
Walking/Mobility
Toileting
Medications
Household Management
Independent w/Assistance (Describe) Unable
Meal Preparation
Food Shopping
Light Housework
Laundry
Transportation
Mail
Bill/Money Management
Adaptive Devices/Equipment
Item Description Repair/Supply Vendor Info
Glasses
Hearing Aid Left Right
False Teeth/Bridge Partial Upper Lower
Arm Brace Left Right
Leg Brace Left Right
Orthodic Inserts Shoes
Cane Straight Pronged
Walker w/ or w/o wheels
Wheelchair Standard Electric
Other
Other
Notes
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Daily Activity Log
Use this sheet to write down the day’s activities. This will help other caregivers, family members or visitors
know specifics about the elder’s day such as what foods they ate, where they went, who called or visited.
The notes can be brief or detailed.
Date
Breakfast
Morning
Lunch
Afternoon
Dinner
Evening
Above notes written by
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
MEDICATIONS, OVER THE COUNTER AND DIETARY SUPPLEMENTS:
Where meds are kept Pill Boxes used? Yes No Person responsible for filling Pill Boxes
Name Form Dosage For Began End M.D. & Pharmacy Notes
Sneeze Away Pill 1 50 mg 2x/day Allergies 1/1/97 Smith/Rexall 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:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Health Log
Date Time Weight Blood Pressure Blood Sugar Notes
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Medical Information
Medical Diagnoses
Diagnosis Date given Doctor Treatment/Status
Surgeries and Procedures
Date Surgeon Hospital Complications, if any
Hospitalizations and Rehabilitation Stays
Date Hospital Reason Discharge Date Discharged To
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Important Medical Events (heart attack, seizure, fall, surgery, ER/Hospitalization, Rehab stay, etc.)
Date Event Treating Physician
Hospital/Facility
Admitted Reason Discharged Notes
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Important Tests (blood, CAT scan, X-Ray, MRI, etc)
Date Description Ordered By Phone # Test Results Results kept
Name Date of Birth
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved
Physicians
Primary Care
Name
Address
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Name Date of Birth
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved
Additional Specialty Physicians
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Notes
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Notes
Specialty Physician Start Date End Date
Name
Specialty
Hospital/Clinic
Phone # Pager #
Days/Hrs After Hours Instructions
Fax # Email Address
Hospital Affiliation (s)
Notes
Name Date of Birth
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved
Other Medical/Health Professionals
Use this page to note other health professionals such as Chiropractor, Dentist, Ophthalmologist,
Optometrist, Audiologist, and Podiatrist. After their name, write the type of care they provide.
Name
Address
Phone # Fax #
Days/Hrs After Hours Instructions
Pager # Web/Email Address
Name
Address
Phone # Fax #
Days/Hrs After Hours Instructions
Pager # Web/Email Address
Name
Address
Phone # Fax #
Days/Hrs After Hours Instructions
Pager # Web/Email Address
Name
Address
Phone # Fax #
Days/Hrs After Hours Instructions
Pager # Web/Email Address
Name
Address
Phone # Fax #
Days/Hrs After Hours Instructions
Pager # Web/Email Address
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Call Log
Date/Time
Notes = Spoke with, Agency Name, Phone#, What was discussed To Do?
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Upcoming Doctor Visit
Appointment Date Time
Doctor’s Name Specialty
Office/Clinic Location Phone
Reason for visit (current symptoms)
Remember to bring:
Questions/Concerns to discuss
Q:
A:
Q:
A:
Q:
A:
Additional Notes
Tests Done Results/Call for results
Outcome - Diagnosis and Next Steps
Diagnosis
Additional Tests Treatment Scheduled for What to Expect
Medication Changes
Follow Up Appointment Date and Time Remember to bring
Other Notes:
Above notes written by
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Location of Key Documents - CONFIDENTIAL
Document Location Date Noted
Social Security Card
Medicare Card
Secondary Health Insurance Card
Health Care Proxy
Living Will/Advance Directive
Power of Attorney
Guardianship
Conservator/Representative Payee
Life Insurance Policy(s)
Will
Trust Information
Military ID/Papers
Real Estate Property Deeds
Bank and other Financial Documents
Note: Specify Name of Bank, Financial Institution or Company
Document Location Date Noted
Loan Documents
Annuity Contracts
Stock Certificates/Bonds
Bank Vault/Safe Deposit Box (es)
Bank Location Date
Box # Location of Key
Add’l Name/Signatures on file
Bank Location Date
Box # Location of Key
Add’l Name/Signatures on file
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Legal, Investment and Accounting Contacts
Attorney
Name
Firm Name www.
Address City State Zip
Office Phone Cell Phone
Email Assistant’s name
Office Hours
Financial Advisor/Planner
Name
Firm Name www.
Address City State Zip
Office Phone Cell Phone
Email Assistant’s name
Office Hours
Stock Broker/Investment Consultant
Name
Firm Name www.
Address City State Zip
Office Phone Cell Phone
Email Assistant’s name
Office Hours
Accountant/Tax Advisor
Name
Firm Name www.
Address City State Zip
Office Phone Cell Phone
Email Assistant’s name
Office Hours
Other
Name
Firm Name www.
Address City State Zip
Office Phone Cell Phone
Email Assistant’s name
Office Hours
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Insurance
Home
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Automobile
Car 1 Make Model Year
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Car 2 Make Model Year
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Life
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Disability
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Long Term Care
Policy#
Agent Name Phone #
Agency Name www.
Address City State Zip
Insurance Company/Underwriter www.
24 Hour Claim Phone #
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Banking Information - CONFIDENTIAL
Bank Name www.
Address City State Zip
Phone Branch where Acct was opened
Contact Person Direct line
Email address Branch Days/Hours
Checking Account # Add’l Name on Acct
Savings Account # Add’l Name on Acct
Money Market Account # Add’l Name on Acct
On Line Banking Website UserID Password Clue
Certificates of Deposit
Term Amount Start Date Maturity Date Notes (auto rollover, etc.)
Bank Name www.
Address City State Zip
Phone Branch where Acct was opened
Contact Person Direct line
Email address Branch Days/Hours
Checking Account # Add’l Name on Acct
Savings Account # Add’l Name on Acct
Money Market Account # Add’l Name on Acct
On Line Banking Website UserID Password Clue
Certificates of Deposit
Term Amount Start Date Maturity Date Notes (auto rollover, etc.)
Bank Name www.
Address City State Zip
Phone Branch where Acct was opened
Contact Person Direct line
Email address Branch Days/Hours
Checking Account # Add’l Name on Acct
Savings Account # Add’l Name on Acct
Money Market Account # Add’l Name on Acct
On Line Banking Website UserID Password Clue
Certificates of Deposit
Term Amount Start Date Maturity Date Notes (auto rollover, etc.)
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Income, Expenses and Net Worth – CONFIDENTIAL
Social Security #
Income Expenses
Social Security $ Rent/Mortgage $
Pension/Retirement $ Other Mortgage $
Annuities $ Bank Loan $
Interest $ Income Tax (Qtrly) $
Dividends $ Property Tax $
Rent $ Utilities
Other: $ Phone $
Other: $ Gas $
TOTAL $ 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 $
Assets (own) Liabilities (owe)
Checking Account $ Mortgage $
Savings Account $ Second Mortgage $
CD’s $ Reverse Mortgage $
Money Market Funds $ Bank Loans $
Life Insurance (cash value) $ Car Loans $
Approximate Market Value of Credit Cards $
Pension Funds $ Personal Loans $
Mutual Funds $ Other $
Stocks $ TOTAL $
U.S Treasury (bills, bonds) $
Real Estate Equity $
Automobiles $ Total Assets
Personal (Jewelry, Art, Furniture) $ Minus Total Liabilities
Other (boat, etc) $
Other $
TOTAL $
Total Assets $
Minus Total Liabilities $
NET WORTH $
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
Monthly Bills
Expense Name Account # Phone # Due Date
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
Notes
Quarterly Bills
Expense Name Account # Phone # Due Date
Property Tax
Estimated Income Tax
Water
Other
Other
Notes
Name: Date of Birth:
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
© 2008 Springwell, Inc. All Rights Reserved.
End of Life Instructions
End of Life discussions and decisions can be difficult. This page is to serve as a starting point in discussing and
gathering the information. We encourage you to speak with the Primary Care Physician and call Springwell for
more information and assistance with this complex topic. For detailed information on End of Life care and answers
to frequently asked questions, go to www.endoflifecommission.org, or call 617-636-3480. To order a copy of “Five
Wishes”, a document to put your wishes on specific treatment and care in writing, go to: www.agingwithdignity.org
or call 888-594-7437.
Health Care Proxy/Advance Directive completed? Yes No On File with Dr.
Includes the following requests:
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
)
Health Care Agent Relationship
Contact Instructions
Home # Work # Cell #
Family/Friend to be notified
Name Relationship
Contact Instructions
Home # Work # Cell #
Name Relationship
Contact Instructions
Home # Work # Cell #
Name Relationship
Contact Instructions
Home # Work # Cell #
Attorney to be notified
Name Firm Name
Address City State Zip
Phone # Cell #
Clergy to be notified
Name Phone #
Address City State Zip
Funeral Home
Address City State Zip
Phone # Pre-Paid
Cemetery
Address City State Zip
Phone # Pre-Paid Lot#
Other instructions
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Resources
Springwell, Inc.
125 Walnut Street
Watertown MA 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
307 Waverley Oaks Road Suite 205
Waltham, MA 02452
Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Notes
Springwell, Inc.
125 Walnut Street
Watertown MA 02472
617-926-4100
TTY: 617-923-1562
Fax: 617-926-9897
www.springwell.com
inforef@springwell.com
307 Waverley Oaks Road Suite 205
Waltham, MA 02452
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