Personal Caregiving Record

Self Help Tools 

The Personal Caregiving Record should be printed and completed for your dependent older adult. Once completed, this record will help you to remember and other caregivers to know your older adult. This will help ensure that your older adult receives consistent care even when there are multiple caregivers.

To see and print the Personal Caregiving Record in PDF format.
Please click here

Acrobat reader allows you to see and print PDF documents, if you do not have Acrobat reader you can download it for free from this link:

The caregiving record has several areas:

Personal Information

General Daily Routine

Health Information

Leisure And Recreational Activities

Activities Of Daily Living (ADL's)

Suggestions For Caregiver

Personal Information

My Name Is ________________________________________________

I Like To Be Called __________________________________________

I Am __________ Years Old

I Am Married ______ Not Married _______

My Spouse's Name Is ________________________________________

We Have Been Married ___________years

I Have _______________________ Children

1. ___________________________ 2. __________________________

3. ___________________________ 4. __________________________

I Have ___________________ Grandchildren

1. ___________________________ 2. __________________________

3. ___________________________ 4. __________________________

My Children Live In

1. ___________________________ 2. __________________________

3. ___________________________ 4. __________________________

My Favorite Possessions Are (Afghan, Stuffed Animal, Etc.)

__________________________________________________________

__________________________________________________________

Back to top of this page

Health Information

A. Telephone Information

Doctor ____________________________ #______________________

Doctor ____________________________ #______________________

Ambulance _________________________ #______________________

Poison Control ______________________ #______________________

Family Member ______________________ #______________________

__________________________________ #______________________

Neighbor ___________________________ #______________________

Minister ____________________________ #______________________

B. Allergies __________________________________________________________

C. Special Treatments (Compresses, Etc.) _________________________

__________________________________________________________

D. Physical Aids (Glasses, Dentures, Etc.) _________________________

__________________________________________________________

__________________________________________________________

E. Memory Loss _____________________________________________

F. Medications

Name_________________ Dosage_____________ When_________

Name_________________ Dosage_____________ When_________

Name_________________ Dosage_____________ When_________

Name_________________ Dosage_____________ When_________

Name_________________ Dosage_____________ When_________

Name_________________ Dosage_____________ When_________

Possible Side Effects

__________________________________________________________

__________________________________________________________

__________________________________________________________

Back to top of this page

Activities Of Daily Living (ADL's)

A. Personal Care

Toileting __________________________________________________

_________________________________________________________

Grooming _________________________________________________

_________________________________________________________

Bathing ___________________________________________________

_________________________________________________________

B. Eating Habits

Special Diet _______________________________________________

_________________________________________________________

Likes and Dislikes___________________________________________

_________________________________________________________

Chewing or Swallowing Problems _______________________________

_________________________________________________________

Use of Knife, Fork, Spoon, Etc. ________________________________

_________________________________________________________

C. Favorite Snacks _________________________________________

_________________________________________________________

D. Special Habits __________________________________________

_________________________________________________________

E. Problems In and Outside the Home

Walking __________________________________________________

Stairs ____________________________________________________

Barriers __________________________________________________

Wheelchair, Walker, Cane ____________________________________

_________________________________________________________

Additional: ________________________________________________

_________________________________________________________

Back to top of this page

General Daily Routine

Breakfast _________________________________________________

Nap _____________________________________________________

_________________________________________________________

_________________________________________________________

Supper ___________________________________________________

_________________________________________________________

Bedtime __________________________________________________

_________________________________________________________

Back to top of this page

Leisure And Recreational Activities

Favorite TV Shows __________________________________________

_________________________________________________________

_________________________________________________________

Picture Books _________________________________________________________

Playing Cards _________________________________________________________

Short Strolls _________________________________________________________

Naps _________________________________________________________

Conversation _________________________________________________________

Local Newspapers _________________________________________________________

Radio _________________________________________________________

Music _________________________________________________________

Back to top of this page

Suggestions For Caregiver

1. Face the person when you speak to them.

2. Establish eye contact.

3. Use hand gestures (point).

4. Speak distinctly, calmly, softly.

5. Use simple sentences.

6. Allow ample time for answers.

7. Minimize background noises.

8. Touch only when acceptable.

9. Do not over use the word "no" - yes or maybe might be adequate.

10. Sudden, quick, unexpected movements can be frightening.

11. Let person know time of day, where they are and what is going on every now and then.

Back to top of this page