Record the people and services you would want to reach. Confirm that contacts agree to be listed and know what help you may ask for. Keep this completed sheet where the right people can find it.
Print and keep: Use your browser’s Print command (Ctrl+P or Command+P), then print or save as PDF. Fill in the worksheet by hand. This page does not collect or save your information.
Name: ____________________________ Last updated: ________________
Address or location details: _________________________________________
People I trust
| Name / relationship | Phone | Backup contact method |
|---|---|---|
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
| ________________ | ________________ | ________________ |
Care and local information
| Contact | Name / organization | Phone |
|---|---|---|
| Primary care | ________________ | ________________ |
| Pharmacy | ________________ | ________________ |
| Equipment supplier | ________________ | ________________ |
| Local support / transport | ________________ | ________________ |
My plan
Local emergency number: __________________________________________
Where we will check for local instructions: ____________________________
Where my current medication list is kept: _____________________________
Agreed meeting place or next contact: _________________________________
For an immediate emergency, contact your local emergency service. Keep detailed health information, identity numbers, and other sensitive records securely rather than adding unnecessary information to a widely visible sheet.
Further reading: Ready.gov: planning for older adults