Eating Habits
Describe things like whether snacks are allowed, how often, types? Any precautions to be taken with monitoring them while eating, special utensils, etc.
Special Food Considerations
Describe foods to be avoided for swallowing considerations, gas, etc., whether meals should be prepared in a certain way (cut into small pieces, pureed, soft-foods, thickeners added, etc.)
Drinks
Describe liquids to be avoided, whether thickeners need to be added, favorite drinks, etc. If there are special recipes or prepared drinks identify them.
Sleeping Habits
What are their normal sleeping schedules? Should they be kept awake certain hours? What clothing do they prefer to sleep in? Do they prefer sleeping on their side or back? Is it okay for them to sleep on couch or other area?
Hobbies & Interests
Describe/let caretaker knows if there are items around the house reflecting the persons hobby/interest that could be brought out and talked about. Do they participate in a hobby on a regular basis, etc?
Social Support
Are there special people in their life who they may want to talk with or have visit? Who is allowed to visit in your absence? Who is not?
Name __________________________ Phone ______________
Address_____________________________________________
______________________________________________
City State Zip
Who they are: _______________________________________
They are: ___ Allowed To Visit Anytime ___ Must Call First
__ Must Wait Until You Return
Name __________________________ Phone ______________
Address_____________________________________________
______________________________________________
City State Zip
Who they are: _______________________________________
They are: ___ Allowed To Visit Anytime ___ Must Call First
__ Must Wait Until You Return
Name __________________________ Phone ______________
Address_____________________________________________
______________________________________________
City State Zip
Who they are: _______________________________________
They are: ___ Allowed To Visit Anytime ___ Must Call First
__ Must Wait Until You Return
Other Considerations
Identify all other things the caretaker should be aware of in your absence. Make sure they know where a copy of the EMERGENCY INFORMATION & DAILY MEDICATION SHEETS are that lists all critical contacts, phone numbers, etc. and provide specific medical information on your loved one. (Post them on the refrigerator)
