Questions and Content for Your Personalized Care Plan

Every caregiver deserves a clear path forward. This form will help you create a personalized care plan that’s easy to follow — giving you confidence and peace of mind. When you complete the form, you’ll get your own copy with all your answers filled in — ready to use, share with family, or bring to appointments.

Personal & Emergency Information

First Name

Last Name

Phone

Emergency Contact(s)

DOB

Preferred Hospital

Preferred Doctor

Allergies

Insurance Provider and Policy #

Medical & Health Care

Current Diagnoses

Medications (name, dosage, frequency, prescribing doctor)

Special Instructions (mobility, diet, equipment)

Daily Care Needs

Morning Routine (meals, meds, hygiene, mobility support)

Afternoon Routine (rest, activities, therapy, social)

Evening Routine (meals, meds, hygiene, relaxation)

Sleep Preferences

Things that help them feel safe/calm

Support Network

Who’s on the care team (family, friends, professionals)

Roles/responsibilities (transportation, meals, finances, emotional support)

Backup contacts if primary caregiver unavailable

Legal & Financial Essentials

Power of Attorney (name + contact)

Advance Directive / Living Will

Key Financial Contacts (bank, lawyer, advisor)

Important Documents (location of originals)

Emotional & Social Care

Favorite Activities / Hobbies

Social Connections (friends, groups, religious/community support)

Stress Signs to Watch For

Comforting Routines or Rituals

Weekly / Monthly Review Page

What’s Working Well?

What Needs Adjusting?

What New Challenges Came Up?

Next Steps.