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

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