Our Final Journey

Forms, Checklist

Tools For Viewing
Let's Talk About It
Section 1 - Assistive Technology
Section 2 - Divorce Issues
Section 3 - Drugs/Medications
Section 4 - Checklist, Documents, Forms
Section 5 - Employment Issues
Section 6 - Estate Planning
Advanced Directives & DNR's
Section 7 - Caregiver Resources
Patient Quality of Life: Should Doctors Guess It?
Incontinence Care
Section 8 - Children Seriously Ill
Children of The Chronically Ill
Siblings of Children with Special Health Needs
Guides To Disability Issues
End Stage Hospital & Home Care
Child With A Serious Illness
Individual Family Service Plan (IFSP)
Camps-Special Needs Children
Children's Wish Foundations
Section 9 - For Kids
Section 10 - Family Resources
Section 11 - Patient Resources
Section 12 - Financial Aids
Section 13 - Insurance
Long Term Care Insurance
Section 14 - Legal
Section 15 - Long Term Care
Section 16 - Symptom Support
Section 17 - End of Life
Section 18 - Funeral Planning
Section 19 - After Death Occurs
Hospice FAQS
Symptom Support
Behavoir Strategies
Ill Person's Feelings
Caregiving & Family Harmony
Caregiver Grief ~Article
End of Life
Comforting A Dying Person
End Stages of Life
When Someone Dies
Funeral Planning
Bereavement Fares and Discounts
Common Bonds of Caregiving
Tips For Helping Your Friend
About me
Free Greeting Cards
Estate Planning Definition
Living & Other Trusts
Wills & Beneficiaries
State Laws On Wills
Conservator~Guardianship Definitions
Insurance Issues
Avoiding Probate
Prescription Drug Program I
Prescription Drug Cards II
Disability & SSDI Insurance Questions
Long Term Care Insurance
Employment Issues
Divorce Issues
State Laws-Statutes
Making A Personal File
Emergency Info Form
Emergency Planning
Health Care Surrogate
Forms, Checklist
Family Resources
Patient Resources
Rehab Tools-Assistive Tech. Categories
State Map-Ombudsman Program
NH Your Rights-Fact Sheets
Nursing Homes and Your Rights - Factsheets for some seriously ill or their caregivers.
Long Term Care-Facts & Rights
State & Federal Resources
Drug Resources
Grief & Sorrow
When death nears - Signs and Symptoms
Some Facts About Artificial Nutrition and Hydration
Things To Consider-Artificial Nutrition and Hydration
Some of these checklists have been developed by The Consumer Consortium on Assisted Living (CCAL), a national, nonprofit organization dedicated to representing the needs of consumers in assisted living facilities and educating consumers, professionals, and the general public about assisted living issues.   Where you see WORD DOC, click on it for document inWORD  format. The rest are forms or checklist located on the site it is linked to.
Keep track of questions asked doctors, answers etc.
Assisted Living: Costs And Contracts 
A list of financial questions to ask when you and your loved one visit an assisted living facility.
Assisted Living: Quality Of Life
A checklist of questions dealing with socializing, meals, safety, and other issues to consider when you and your loved one visit an assisted living facility.
A checklist of personal and health care questions to ask when you and your loved one visit an assisted living facility.
Assisted Living: Special Care Units If your loved one is considering a move to assisted living, you need to find out about any special care services offered by the facility.
Better Family Communications
The better family members can communicate with each other, the better they can deal with hard times and difficult decisions.
Caregiving Decision Questionaire
A brief list of questions to help you set prioities and solve caregiving problems.
Use copies of this form to monitor daily changes and help with communication among care providers working in shifts.
Choosing A Rehabilitation Program  A list of questions to consider as you and your loved one prepare to choose a rehabilitation program.
Choosing the Right Doctor
Consider the following questions and steps as you and your loved one evaluate physicians.
Continuing Care Questionnaire
A list of questions to ask when you and your loved one visit a continuing care retirement community.

CPR-Everything You Wanted To Know (in PDF format) Cardiopulmonary Resuscitation (CPR) includes a group of procedures used when the heart stops beating.
Daily Caregiver Instruction form WORD DOC A form to provide complete information on your loved one for temporary caregivers/sitters/CNA, etc. who come to your home.  Explains routines, special care instructions,favorite TV schedules, etc.
Daily Needs Assessment Sheet WORD DOC This worksheet will help you and other family members determine what types of assistance your loved one needs.
A braclet with your medical condition and emergency contacts.
Driving: An Assessment Checklist WORD DOC
If you are unsure about your loved ones ability to drive, this checklist can help
Driving Adaptations
A look at some types of adaptive equipment that may make it easier for your loved one to drive.
Driving-Losing The Ability to Drive/Article - Generally, no individual plans for a time when he or she will no longer be able to drive. In fact, your loved one probably assumes that he or she will know when to stop driving. Most individuals, however, never realize that it is time to stop driving.
Driving Adaptations
A look at some types of adaptive equipment that may make it easier for your loved one to drive.
Driving-Alternative Transportation Programs - Making sure that your loved one has reliable transportation to the doctors office and other important appointments can be one of a caregivers most difficult tasks. Transportation can be a tough issue for many caregiving families. The issue is even more difficult if your loved one has mobility problems. Until you have to arrange it, it doesn't seem that something as basic as getting your loved one to a doctors appointment should be so hard. But for most families, it is. Here's how to begin solving this problem.
Enter your zip code to learn about alternative transportation in your area.
Guidelines for 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 check-list to talk to members of the health care team.
Helpful Forms
Forms in Word document that you can download and modify to meet your needs.  For caregivers, family planning, etc.  Although some are written for Huntington's Disease, most are for any situation.  

Holiday Help for Caregivers of the Terminally Ill -The most important consideration of a holiday season is to look for ways to streamline your stress. This site provides some suggestions.

Excellent links to home modifications and checklists from the National Resource Center on Supportive Housing and Home Modifications
Home Modification Checklist-What You May Need -Use this checklist to spot possible safety problems that may be present in your loved ones home. This checklist is organized by areas in the home.
and Accessibility -Overall description of a whole list of things to help with
adaptability and accessibility in your home.
Home Modification-Home or Office Accessible Homes where you can learn more about adapting your home or office to make it more accessible and convenient for the disabled, Loans for People With Disabilities, HUD 203k loans available for disability remodeling etc.
Step by step descriptions and diagrams on how to modifiy a bathroom to be handicapped accessible.
Step by step descriptions and diagrams on how to modifiy a kitchen to be handicapped accessible.
Home Modificiation - Stairs and Ramps  Step by step descriptions and diagrams on how to modifiy steps or add ramps to be handicapped accessible.
Home Modificiation - Funding Resources  - 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.
Here is 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:

-Architects/ Contractors
-Government Grants/ Funding
-Assessment Tools/ Instruments
-General Modifications
-Universal Design
-Publication/ Printed Materials
-Products: Bathing, Floors, Grab Bars, Hearing Impairment,
 Lifts, Ramps, Stair Glides, Toileting,
-Assistive Technology
These resources are designed to help consumers make good decisions about the products they need to improve their home environment. From the Natioinal Resource Center on Supportive Housing and Home Modifications includes products, catalogs, articles, software etc.
Home Modification - Visitable Homes  - Construction guidelines make homes generally "visitable". Many people with mobility limitations could also occupy these houses with little or no modification. Because the guidelines are for private, single-family dwellings, or for renovations of houses and apartments not mandated by existing law, no special "access" codes or additional regulations apply.
A form to complete for every member of your family with complete instructions on medications, insurance, emergency contacts, etc.
Medical History Chart-Making a Personal One   In addition to the doctors medical history chart, a personal health history is an excellent resource, as it provides a consolidated history of all medical care and conditions over a stated period of years. Doctors find this information especially useful, even critical, when prescribing drugs or preparing treatment plans. It can alert them to any complications that might exist based on previous conditions or medications. A sample chart to help you document your loved one's medical history.

Medical Appointments-Record Changes To Discuss With Your Doctor  - Use this form to keep track of your medical appointments.
Medicare-Medicaid Payment Options Chart-A summary of many of the services covered by Medicare, Medicaid, and other government programs These charts may not cover every case possible, and should be used as a reference tool for discussing your pay options with a local qualified professional
Medication: New Drug Checklist-Q&A's  WORD DOC 
A New Drug Prescription Checklist, questions to ask the doctor.
A form to help you chart eating-related side effects of your loved ones medications. Written for chemotherapy but usable on any med.
Medication - Weekly Chart (cross off after taking) - Here's a handy record to help keep track of what medicines to take every day, when to take them, and when he or she took them. Write name and date, starting on Sunday, at the top of the record.

Medication Weekly Check-off Chart (larger version)

Needs Assessment Worksheet
This worksheet will help you and other family members determine what types of assistance your loved one needs.
Nursing Home Checklist 
A list of basic questions to ask when you and your loved one visit a nursing home.
Social Services Q&A Checklist WORD DOC Use this form to keep a record of in-person and phone interviews with social service agencies.
A form to help you track rehabilitation goals and successes.


African American Perspectives on End of Life  - As with other cultural groups, African Americans' views and behaviors around death and dying are complex and wide-ranging. The Community Ethics Program (CEP) at the Albert Einstein Healthcare Network is engaged in one effort to explore the attitudes, values and beliefs about end-of-life care within various ethnic communities.
Assuring Cultural Competence In Health Care -Office of Minority Health national standards that respect language and culture.
Diversity & Culture-Find Our Way: Living With Dying. In PDF format A news article on Breaking Barriers: Doctors, patients must speak same language to bridge cultural divide.

Email Webmaster~Jean E. Miller