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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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Thoughts and stories from others
  1. June 19, 2011 at 10:31 pm | Posted by Cat Koehler, Social Media Advocate, Home Instead

    Hi Keeter. You can download the worksheets by clicking the links on this page. You can also contact your local Home Instead Senior Care office. The number to the Indianapolis office is 317-252-4472.

    Reply

  2. June 19, 2011 at 5:02 pm | Posted by Cindy

    I have just recently in the past 2 years experienced dealing with the issues of caring for 3 senior parents. Their health issues and death issues. What a rollercoaster it has been. I will say one of the most IMPORTANT items you should have for your parents is a Durable Power of Attorney and a Power of Attorney for Healthcare and it must be stipulated in the POA what is to be done with the body at time of death.Notorized of course. The healthcare system and banking system is not forgiving should you not have these items and your parent is incapacitated or has died. If you have these 2 POA'S on your parents noone can deny you authorization to make decisions on their behalf. That will encompess everything from making payments, closing accounts, collecting on life insurance, annuities, burial decisions,medical insurance claims etc. Dont let anyone tell you one POA is good enough because its NOT. Double coverage on this matter is the best way to deal with legalities. Been there done that!!!

    Reply

  3. June 18, 2011 at 4:52 pm | Posted by Chuck McGuire

    I really like the format of the listings provided for detailing contacts, prescriptions, etc. but I wish they were in a format that information could be keyed in and saved electronically and transmitted or mailed to family members.

    Reply

  4. June 18, 2011 at 2:32 pm | Posted by Keeter Sechrist

    I would like to order a kit...I have one already for my father and would like to set one up for my mother-in-law. Thank you.....Keeter D Sechrist 6335 No Ewing St Indianapolis, In 46220 Thank you....Keeter Sechrist

    Reply

  5. June 18, 2011 at 12:47 am | Posted by Mary Kifonidis

    Hi. I downloaded your fabulous charts for medications, trackers, etc.; however, how do I now type in the information? I'm unable to type in the form after I downloaded it to my Mac Laptop.

    Reply

  6. June 17, 2011 at 11:44 am | Posted by Belinda Peterson

    I think families would be willing to pay a modest amount for these kits , and I could offer them upon discharge from my nursing home. I think a 3-ring binder with sheet protectors would be easier to use. Belinda

    Reply

  7. June 16, 2011 at 6:34 pm | Posted by Steve Nooyen

    Good stuff! I thought the downloadable materials were well designed. Thanks.

    Reply

  8. June 16, 2011 at 2:44 pm | Posted by Cat Koehler, Social Media Advocate, Home Instead

    The Senior Emergency Kit is a wonderful tool. Go to http://www.homeinstead.com and enter your zip code to find the office nearest you. You can contact them for the kits. You can also print the inserts at http://www.SeniorEmergencyKit.com.

    Reply

  9. June 16, 2011 at 8:56 am | Posted by Pam Drane

    As director of a seniors camping club I think it would be a great idea for our members to have this kit especialy while traveling. Is it possible to receive kits so I can hand them out at our next gathering?

    Reply

  10. June 15, 2011 at 4:29 pm | Posted by One Family’s Tragedy… « Home Instead Senior Care of Wichita, Kansas

    [...] toolkit includes checklists and worksheets for medications, conditions, allergies, doctors, health advisors and important [...]

    Reply

  11. June 13, 2011 at 4:19 pm | Posted by sarah kamman

    Absolutely the best information I have seen in many years. Had a delightful visit with your local representative ( Midland, TX) this morning. Will do all I can to help get the word out. Thanks a million.

    Reply

  12. June 13, 2011 at 3:01 pm | Posted by How to Organize Elder Care | Home Care Torrance

    [...] toolkit includes checklists and worksheets for medications, conditions, allergies, doctors, health advisors and important documents. You can [...]

    Reply

  13. June 11, 2011 at 3:01 pm | Posted by Trevor Roberts

    I also find as I am getting older, is details, I find it very helpful to keep almost a daylog of my health and well being noted down, no matter how trivial, it is helpful to take to the Doctor or ER visits when they need too. Gives an instant history of you, over the past while. Great forms, great idea, we have similar one with "Vial of Life" pill bottle with meds etc in fridge with magnet on front, for use by emerg personnel.

    Reply

    • May 12, 2012 at 12:29 pm | Posted by Ewelina

      Hey Andy, I opened the woksrheet and filled out all the answers, but WHOOPS! How do I send them in or save them? It just opens in another window with no other options. Also I cannot copy the answers

      Reply

  14. June 11, 2011 at 1:50 pm | Posted by Olson, George

    Where is the kit???????????????

    Reply

  15. May 22, 2011 at 7:56 am | Posted by Diane Harlow

    My mother lives in NJ, and the rescue/police know to look on the refrigerator for her info. I think this is something they suggest for the elderly, and it's so easy for them to find.

    Reply

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