The following forms are all available on the HD Helpful Forms
website but am copying them here for ease of
finding. You can also find Word Documents on various articles on HD under the HD Articles of Interest
on the HD Caregiver's Website.
CNA First Shift handout
Huntington's Disease card
Caregivers Document Organizer
form that will help you identify, locate, and organize the important documents your will need as a primary
tips for setting up a notebook to keep track of your caregiving situation*
Use copies of this form to monitor daily changes and help with communication among care providers working in shifts*
(in PDF format) Cardiopulmonary
(CPR) includes a group of
procedures used when the heart stops beating.
Info on HD For Temporary Caregivers
In depth instructions to leave for temporary caregivers.
Prepared by Jean Miller~Word
document is 4 pages providing needed data for EMS or other emergency personnel. This form should be filled out for each member of your family and copies provided to your primary care physician,
one in the glove compartment of each vehicle driven and one posted on
the refrigerator which is where EMS personnel look for information
Personal Health History-Prepared by Jean Miller-Word document is 5 pages.
This document provides the medical history on an individual.
A form to help you keep track of your loved ones personal records and other important information*
Picture Cards-Prepared by Jean Miller
of communication cards that can be copied or made up to help your loved one with relaying their needs.
|Sample Filing System
Listed below is one possible method for setting up a home filing system. You should adopt a system that fits your needs and those of your family*
Special Care Instruction booklet
Prepared by Jean Miller-The following pages are
from a 12 page Word Document that can be modified to include personal information on a loved one requiring caregiving. These provide background on that person to help temporary caregtakers
understand your loved one's individual needs and limitations. When I first made this form it was put together along
with pictures of family members, pets, and a "picture-board" of words called "Kelly's Caregiving Handbook".
A handout to remind caretakers to respect the dignity of your loved
one and not to treat them differently because of Huntington's Disease.
Anxiety Questionnaire, Delirium Quick
Recognition, Delusions Questionnaire, Depression Questionnaire,
Disinhibited Behavior Questionnaire, Dyskinesia Self
Evaluation Form, Hallucinations
Questionnaire, Mood Swings Questionnaire, Sleep Questionnaire, Quality of Life
HD Activities of Daily Living Rating Chart 4pgs This chart can
be printed out and used to measure noticable changes to discuss with your physician.
Functionality Tests - Various assessment tests used for daily living, cognitive abilities, children, gait (walking), quality
of life, etc.
Needs Assessment Worksheet (ADL)
LETTERS FOR YOUR DOCTOR:
Letter to Doctor-Medications
-Prepared by Jean Miller-A sample letter for your primary care physician identifying all of the prescribed medication and
OTC products you are taking requesting that they
manage those to advise you of any problems or interactions.
a Personal Medical History Chart
A sample chart to help you document your loved one's medical history
Medical History form
Medication & OTC Form-Prepared by Jean Miller Word document is 2 pages. This document is to
provide a list of all prescription medications and over the counter (OTC) products used by an individual.
This should be attached to the Personal Emergency Information form above.
Medication Direction & Check Off Chart
Medication Weekly Chart-Check Off
Track of Side Effects Form
OUTSIDE OF HOME
Living-Questions To Ask
Services Q&A Checklist
Information, forms and tips to help you with estate planning, including Personal Papers, Insurance, Living
Trusts, Wills, Conservatorship/Guardian, etc.
Quality Care-Evaluating Quality of Care Checklist (in PDF format) Although there are no "report cards" or accepted national standards
yet available for judging quality end-of-life care, these are some questions you can ask to evaluate care. These can be used
to help select providers and are also helpful if a loved one is dying and you are uncertain of the quality of care they are
receiving. Use this checklist to talk to members of the health care team.
Is Estate Planning Document
What Is A Conservatorship-Guardianship?
Valuable Records Form
Step by step descriptions and diagrams on how to modifiy a bathroom to be handicapped accessible
A collection of commonly asked questions received by the National Resource Center for Supportive Housing and Home Modifications. These
questions are dividied into topic categories for your convenience. Information on
several topics including Bathing, Floors, Grab Bars, Hearing Impairment, Lifts, Ramps, Stair Glides,
Toileting, and Assistive Technology
State and Local Funding - Many states
and localities provide special grants and loans to their residents for home. This
site offers suggestions on how to find that funding.
Step by step descriptions and diagrams on how to modifiy a kitchen to be handicapped accessible.
Excellent links to home modifications and checklists from the National Resource Center on Supportive Housing and Home Modifications
Step by step descriptions and diagrams
on how to modifiy steps or add ramps to be handicapped accessible.
End of Life
|Are You Grieving?
A checklist of the physical, mental, and behavioral symptoms of grief*
Information on sensitive decisions that need to be considered, things to help you, your family
and loved one in the final stages of life.
|Funeral Planning Checklist|
A list of all of the issues to consider when planning a funeral*
|Funeral Planning Form
As your loved one makes his or her funeral plans, use this form to record all of his or her wishes for final arrangements*
Locate a Hospice in any city/state at this website. To learn more about hospice care or to find a hospice in the United States call 1-800-658-8898,
or search the NHPCO hospice database. Select a state you are interested in or type a provider name and then click search. The search will display a list of cities and
counties in the specified state that are served by hospices.
From Family Care America