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Senior Emergency Kit Worksheets and Checklists

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April 26, 2011

The Senior Emergency KitSM features several worksheets that family caregivers can complete with the help of a senior loved one. This toolkit can be kept in an easy-to-reach location, such as a nightstand, to allow easy access to information.

Checklist of Things to Have in Your File

Keep these documents about your senior loved one in your information management tool file:

The toolkit is part of the Home Instead Senior Care® network's Answering the Call® program designed to help family caregivers be ready for a call when a senior loved one needs emergency assistance.

Download individual senior emergency tracking kit components below…

Important Contacts

It's important that a family caregiver has easy access to the medical and business professionals that manage their senior's affairs in the event of an emergency. List on the worksheet all of those individuals with whom your senior does business.
Important Contact Information Worksheet (PDF 732k)

Life History Snapshot

Use this worksheet to record key details pertaining to each stage of your senior's life from childhood through older adulthood. Documenting this type of background information is particularly important for a loved one with Alzheimer's or other dementias to help cope with memory loss or manage difficult behaviors.
Life History Snapshot Worksheet (PDF 632k)

Medications and Dosages

Tracking medications is one of the most important exercises that a family caregiver can do to help keep an older adult safe from medication accidents. This worksheet is a valuable resource to keep all of a senior's medications and dosages up-to-date.
Medication Tracker Worksheet (PDF 331k)

Allergies and Conditions

Your loved ones and any emergency workers who may assist your senior in a medical crisis should be aware of allergies or conditions that a senior is suffering from, including:

  • Foods
  • Seasonal Allergies
  • Medications
  • Heart Problems
  • Diabetes
  • Arthritis
  • Macular Degeneration

Allergies and Conditions Worksheet (PDF 247k)

Dementia-Related Behaviors Chart

Behaviors associated with Alzheimer's or other dementias may become more evident as the disease progresses. Use this chart to track the prevalence of these behaviors.
Dementia-Related Behaviors Chart (PDF 654k)

Doctor Visit Worksheet

Doctor visits can be confusing for older adults. Take this doctor visit worksheet to an appointment so you can write down questions, answers, and what you need to do next.
Doctor Visit Worksheet (PDF 592k)

Senior Emergency Wallet Card

Keep emergency information quickly available wherever your loved one goes. Information such as emergency contacts, medical data and a medical conditions list are easily available with this wallet card.
Emergency Wallet Card (PDF 210k)

Download the complete Senior Emergency Toolkit (PDF 3.9 mb)

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« Older Comments

  1. February 21, 2013 at 2:08 pm | Posted by Sandra

    Thank you for all the valuable information and the pdf files. I am getting ready to open up a 103 unit Independent Living Facility for Seniors and am looking for a holder to go on the refrigerators of each apartment to hold the medical, health, etc. information in case there is an emergency and the informaiton will be close at hand for those called to the emergency. Do you know of any companies or websites for such containers? Thank you, Sandra Brodbeck Senior Living Assistant The Pinnacle at EdenHill

    Reply

    • March 4, 2013 at 9:36 am | Posted by Cat Koehler

      Thank you for your comment, Sandra. I have sent you an email to get more information and see how we can help. Cat Koehler Home Instead Senior Care

      Reply

  2. July 14, 2012 at 12:15 pm | Posted by Dan

    I can download as a pdf file. Is there a way to enter information electronically into the downloaded file (which typically can't be done with a pdf file)? Or do you have to print the file and then hand write the information?

    Reply

  3. April 30, 2012 at 2:32 pm | Posted by TERRELL HUTCHISON

    MY PRINTER HAS CRASHED AND I AM NOT ABLE TO DOWNLOAD THE KIT. COULD YOU MAIL ME A HARD COPY TO ...T.W. HUTCHISON 10413 OLD POST LANE GREAT FALLS, VA 22066 TEL 703-759-2054 MANY THANKS.

    Reply

  4. March 6, 2012 at 6:01 am | Posted by American Heart Association Promotes Senior Emergency Kit | homeinsteadsd

    [...] What do you do when the caregiver needs care? The November issue of Heart Insight, a publication of the American Heart Association, featured an article stressing the importance of caregivers developing an emergency plan and directed readers to Home Instead Senior Care’s Senior Emergency Kit materials on CaregiverStress.com. [...]

    Reply

  5. January 19, 2012 at 3:35 pm | Posted by Heleene

    Thank-you for sending me your Emails,as a registered care giver I am always interested and am excited always to read your mail. Recently I was reprimanded for taking to long with my clients and I feel it is not helpful to people who are in a long term care facility to make them feel like they have to be in a hurry,those with Alzheimer are impacted more than most ,when you are not allowed to do your practice properly,things do get missed. The workload we are challenged with every day is sometimes overwhelming but we all do our best and unfortunately sometimes that is not enough. Are there other ways to help seniors and their family's to cope with all this?

    Reply

    • February 9, 2012 at 11:17 pm | Posted by kathlee pinney

      how funny to come across this message.i was just talking to someone about this very problem..i to worked in a nursing home 30 years ago.i was told also that i was spending to much time with patients..one older lady's glasses were falling apart and i found a small screw driver and took time to fix it for her..another older lady needed help to find her room..i was told not to do these things..it floored me...i never came back to work.i called and told them why..i felt very bad for the people there that i left behind..but damed if you do damed if you don't.i work for homeinstead now.one on one..and i'm there to be of service without someone telling me to hurry it up.thank God for Home Instead...

      Reply

  6. January 17, 2012 at 2:55 pm | Posted by Kenya Daniels

    I want to know more about the company.

    Reply

    • January 18, 2012 at 9:31 am | Posted by Cat Koehler

      Thanks for your comment, Kenya! You can learn more about Home Instead Senior Care at www.HomeInstead.com. Cat Koehler Home Instead Senior Care

      Reply

  7. January 17, 2012 at 2:15 pm | Posted by Halsey Hunt

    Need a gal 65 or so who lives in Vero Beach and wants a companion. I do not have a car so that would be a necessay for them to have one. I was happily married for many years till my wife pased away so I am lonely now for someone to love.

    Reply

  8. December 28, 2011 at 2:25 pm | Posted by Jan Jorgenson

    Hello: I printed copies of the documents provided for the Senior Emergency Kit and am very grateful for this information. I was, however, unable to locate documentation for the following and was wondering if you could let me know where I can access these: •Health Care Proxy •DNR (Do Not Resuscitate) Order •Advance Directives such as Living Will and Durable Power of Attorney •Insurance Policies •Will and Testament •Copy of Medicare/Medicaid Card •Anatomical Gift/Organ Donation Card •Valuables Designation List Thank you kindly for your help. Sincerely, Jan Jorgenson

    Reply

    • December 28, 2011 at 3:59 pm | Posted by Cat Koehler

      Thanks for your comment, Jan! For the items you are still looking for, check with your attorney and doctor. Let me know if you have any other questions. Cat Koehler Social Media Advocate Home Instead Senior Care

      Reply

  9. October 27, 2011 at 8:57 am | Posted by Modifying Your Home for Senior Parents -Quad Cities Senior Care — Bettendorf Moline Senior Home Care

    [...] conditions should be kept on the refrigerator door. Home Instead Senior Care has developed a Senior Emergency Kit with worksheets that can be printed out to help you keep track of this important information for [...]

    Reply

  10. October 15, 2011 at 10:22 am | Posted by Pauline Roy

    I heard about these on LIVE ON FIVE and think it's a marvelous idea. I would need three(3) but am willing to pay for them.

    Reply

  11. August 2, 2011 at 5:09 pm | Posted by Cat Koehler, Social Media Advocate, Home Instead

    If you'd like to receive the Senior Emergency Kit, you can download the forms here or contact your local Home Instead Senior Care office. You can locate your local office using your zip code by going to http://www.homeinstead.com. Cat Koehler Home Instead Senior Care

    Reply

  12. August 2, 2011 at 11:49 am | Posted by Karin Croft

    Washington Post article today says that A PRINTED copy of the Senior Emergency Kit can be requested. How do I do so without publishing my address here??

    Reply

    • January 16, 2012 at 3:18 pm | Posted by Jeanette Downey

      Would you please send a copy of the Senior Emergency Kit to 7861 Third Street West Chester, Ohio 45069

      Reply

    • February 25, 2012 at 12:49 pm | Posted by Aurelie

      Wow. aolmst complete guide on how to deal with emergencies not only for our pets but also for us! up for this post! very informative and concise explanations. thanks for sharing!

      Reply

  13. July 31, 2011 at 11:04 am | Posted by Norman Drew

    What you have here is extremely important and useful, however, there is another electronic way that includes doctors, EMT and ER services. For the past 7 years we have been developing a system to accomodate all the info that you are listing including other critical info in time of emergency. I would like to hear from someone concerning our project which is about to be released at the first of the year. go to www.emedyx.com to view

    Reply

  14. July 26, 2011 at 8:52 pm | Posted by Janie Gay

    Please post an address or phone for more information on .II don't have a printer so I need info mail.Thanks

    Reply

  15. July 16, 2011 at 1:53 pm | Posted by David

    I can't find the "kit" to download. I found individual forms but NOT the "kit". Would be nice to have a link to the package.

    Reply

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