Personal & Emergency Information
Basic details about the person who may need support.
- Full name, date of birth, and preferred name
- Home address and phone number(s)
- Primary language and any cultural or religious considerations
- Insurance information (Medicare, Medi-Cal, private plan, policy numbers)
- Primary emergency contact name, phone, and relationship
- Secondary emergency contact (if applicable)
Medical History
A summary of current and past health conditions.
- Known diagnoses (e.g., dementia, diabetes, heart disease, arthritis, Parkinson's)
- History of strokes, falls, or hospitalizations (with approximate dates)
- Vision or hearing impairments
- History of depression, anxiety, or other mental health conditions
- Any chronic pain conditions
- Cancer history (type and status, if applicable)
- Urinary or bowel concerns
Current Medications & Allergies
A complete list helps the care team identify interactions and gaps.
- All prescription medications (name, dose, frequency, prescribing physician)
- Over-the-counter medications and supplements
- Medication allergies and reaction type (rash, swelling, anaphylaxis)
- Food allergies
- Environmental allergies
- Name and contact for the primary care physician
- Names of any specialists currently involved in care
Daily Function & Mobility
Understanding what the person can do independently and where they may need help.
- Bathing, dressing, grooming, and toileting — independent, needs help, or unable
- Eating and meal preparation ability
- Managing medications independently
- Handling finances and paying bills
- Using the phone and managing appointments
- Transportation and ability to drive
- Mobility status: walks independently, uses cane/walker, wheelchair, or bedbound
- Number of falls in the past 6 months
Home Safety
A quick review of the home environment before the formal evaluation.
- Is lighting adequate in hallways, stairs, and bathrooms?
- Are pathways clear of clutter, cords, and loose rugs?
- Are there grab bars in the shower/tub and near the toilet?
- Are smoke detectors and carbon monoxide detectors working?
- Is the bed at an appropriate height with a clear path to the bathroom?
- Can the person safely use the stove and kitchen appliances?
- Are emergency contact numbers posted visibly?
- Is there a medical alert system in place (if living alone)?
Family Dynamics & Care Goals
The care team benefits from understanding the family context.
- Who are the primary decision-makers for care?
- Who provides daily hands-on care, and who lives nearby vs. at a distance?
- Are there any disagreements among family members about care needs or approach?
- Does the person have an advance directive, healthcare proxy, or power of attorney?
- What are the person's stated wishes (in their own words, if possible)?
- What are the family's top priorities: safety, independence, social connection, or other?
- Are there financial concerns or limitations that affect care decisions?
- Payment source: private pay, long-term care insurance, veterans benefits, or Medi-Cal?
A Note on Privacy
You do not need to have every item on this list. Share what you are comfortable with and what you have available. The care team will work with whatever information you can provide. All details are kept strictly confidential.