HEALTH INFORMATION CAREGIVER’S CHECKLIST
PERSONAL INFORMATION
Name Address Home Phone/Cell Phone Numbers
Date of Birth/Birthplace
Driver’s License Number & State
Medicare Number & Effective Date
Medicaid Number & Effective Date
Case Worker’s Name
Case Worker’s Phone Number
Health Insurance Provider
Health Insurance Address
Health Insurance Group Number
Dental Insurance Provider
Dental Insurance Address
Dental Insurance Group Number
Vision Insurance Provider
Vision Insurance Address
Vision Insurance Group Number
Emergency Contact’s Name
Emergency Contact’s Address
Emergency Contact’s Phone Number
Emergency Contact’s Relationship to Patient
Medical Conditions
Prescriptions/Dosage/Frequency
Diabetes o Yes o No Insulin Dependent o Yes o No
Insulin Dosage/Frequency
Insulin Last Dose/Next Dose
Dialysis o Yes o No Dialysis (Name of Facility)
Dialysis Last Treatment/Next Treatment
Allergies
Surgeries
Medical Devices (Pacemaker/Pain Pump/Oxygen)
Cardiac Bypass/Valve Replacement
Transplant (Heart/Kidney/Liver/Lung)
Joint Replacement
Primary Care Physician’s Name
Primary Care Physician’s Address/Phone Number
Dentist’s Name
Dentist’s Address/Phone Number
Eye Doctor’s Name
Eye Doctor’s Address/Phone Number
Hearing Aid Provider
Hearing Aid Provider’s Address/Phone Number
Dentures/Partial Bridges o Yes o No
Eyeglasses/Contacts o Yes o No
Hearing Aids o Yes o No
Local Ambulance Phone Number