Medical Matters Action Checklists



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Medical Matters Action Checklists The following Action Checklists are included in Chapter 5: Medical History Personal Medication Record Health Care Power of Attorney Medical Orders (Do Not Resuscitate/POLST) 101

Checklist for Family Caregivers Medical History Yes Alcoholism Allergies Alzheimer s disease Arthritis Asthma Birth defects Blood disorder Cancer Cataracts Chromosomal disorder Chronic obstructive pulmonary disease Cystic fibrosis Dementia Depression Diabetes Eczema Endometriosis Epilepsy Gallbladder problems Gastrointestinal disorder Glaucoma Gout Hay fever Hearing loss Heart disease High blood pressure Notes 102

Yes High cholesterol Inflammatory bowel disease Infertility Intellectual disability Kidney disease Learning disabilities Lung disease Lymphoma Macular degeneration Mental disorder Miscarriage, stillbirth Muscular dystrophy Neurological disorders Obesity Osteoporosis Psoriasis Sickle cell disease Skin cancer: basal cell Skin cancer: melanoma Skin cancer: squamous cell Stomach disorders Stroke Thyroid disorder Ulcers Vision impairment Other Notes 103

Checklist for Family Caregivers Blood type: Drug allergy/reaction: Drug allergy/reactions: Drug allergy/reactions: Drug allergy/reactions: Surgery: Purpose: Surgery: Purpose: Surgery: Purpose: Hospitalizations: Cause: 104

Hospitalizations: Cause: Hospitalizations: Cause: Hospitalizations: Cause: 105

Checklist for Family Caregivers Personal Medication Record Personal Information Name: Date of birth: Phone number: Medical Conditions Emergency Contact Name: Relationship: Phone number: Primary Care Physician Name: Phone number: Website: Allergies Pharmacy/Drugstore Name: Pharmacist: Phone number: Website: Notes Pharmacy/Drugstore Name: Pharmacist: Phone number: Website: 106

Name of medication Medications Reason Form Dosage When/How Prescribing physician Be sure to include all prescription drugs, over-the-counter drugs, vitamins, and herbal or dietary supplements. Pharmacy 107

Checklist for Family Caregivers Health Care Power of Attorney The person I care for has a health care power of attorney. The following person (if not me) is the health care agent: Agent s name: The person I care for has named me to be the health care agent. I have a copy of the health care power of attorney. The person I care for has discussed expectations with me, and I understand what he or she wants me to do as a health care agent. The health care power of attorney gives me the responsibility to make the following decisions: The following health care providers have been given copies of the health care power of attorney: 108

Assisted living facility: Nursing facility: Health care agency: 109

Checklist for Family Caregivers Medical Orders (Do Not Resuscitate/POLST) The person I care for does not have a do not resuscitate order (DNR). The person I care for has a do not resuscitate order (DNR). The person I care for has an out-of-hospital do not resuscitate order (OOH DNR). The person I care for wears a state-prescribed out-of-hospital do not resuscitate (OOH DNR) medical alert bracelet. The person I care for has a physician order for life-sustaining treatment (POLST) form. Physician who entered the DNR: Physician who entered the OOH DNR: Physician who entered the POLST: The following health care facilities or providers have the medical orders: Nursing facility: 110

Assisted living facility: Health care agency: Other: 111

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