Medical Matters Action Checklists
The following Action Checklists are included in Chapter 5:
Medical History
Personal Medication Record Health Care Power of Attorney
Medical Orders (Do Not Resuscitate/POLST)
Medical History
Yes Notes
Alcoholism Allergies
Alzheimer’s disease Arthritis
Asthma Birth defects Blood disorder Cancer
Cataracts
Chromosomal disorder Chronic obstructive pulmonary disease Cystic fibrosis Dementia Depression Diabetes Eczema Endometriosis Epilepsy
Gallbladder problems Gastrointestinal disorder Glaucoma
Gout Hay fever Hearing loss Heart disease High blood pressure
Yes Notes High cholesterol
Inflammatory bowel disease Infertility
Intellectual disability Kidney disease Learning disabilities Lung disease Lymphoma
Macular degeneration Mental disorder Miscarriage, stillbirth Muscular dystrophy Neurological disorders Obesity
Osteoporosis Psoriasis
Sickle cell disease Skin cancer: basal cell Skin cancer: melanoma Skin cancer: squamous cell Stomach disorders
Stroke
Thyroid disorder Ulcers
Vision impairment Other
Blood type:
Drug allergy/reaction:
Drug allergy/reactions:
Drug allergy/reactions:
Drug allergy/reactions:
Surgery:
Purpose:
Date:
Hospital:
Doctor:
Surgery:
Purpose:
Date:
Hospital:
Doctor:
Surgery:
Purpose:
Date:
Hospital:
Doctor:
Hospitalizations:
Cause:
Date:
Hospital:
Doctor:
Hospitalizations:
Cause:
Date:
Hospital:
Doctor:
Hospitalizations:
Cause:
Date:
Hospital:
Doctor:
Hospitalizations:
Cause:
Date:
Hospital:
Doctor:
Personal Information
Name:Date of birth:
Phone number:
Emergency Contact
Name:Relationship:
Phone number:
Primary Care Physician
Name:Phone number:
Website:
Pharmacy/Drugstore
Name:Pharmacist:
Phone number:
Website:
Pharmacy/Drugstore
Name:Pharmacist:
Phone number:
Website:
Medical Conditions
Allergies
Notes
Personal Medication Record
Medications
Name of medicationReasonFormDosageWhen/HowPrescribing physicianPharmacy Be sure to include all prescription drugs, over-the-counter drugs, vitamins, and herbal or dietary supplements.Health Care Power of Attorney
The person I care for has a health care power of attorney.
The following person (if not me) is the health care agent:
Agent’s name:
Phone: Email:
Address:
The person I care for has named me to be the health care agent.
I have a copy of the health care power of attorney.
The person I care for has discussed expectations with me, and I understand what he or she wants me to do as a health care agent.
The health care power of attorney gives me the responsibility to make the follow- ing decisions:
The following health care providers have been given copies of the health care power of attorney:
Hospital:
Phone: Email:
Address:
Hospital:
Phone: Email:
Address:
Doctor:
Phone: Email:
Address:
Doctor:
Phone: Email:
Address:
Doctor:
Phone: Email:
Address:
Doctor:
Phone: Email:
Address:
Assisted living facility:
Phone: Email:
Address:
Nursing facility:
Phone: Email:
Address:
Health care agency:
Phone: Email:
Address:
Medical Orders (Do Not Resuscitate/POLST)
The person I care for does not have a do not resuscitate order (DNR).
The person I care for has a do not resuscitate order (DNR).
The person I care for has an out-of-hospital do not resuscitate order (OOH DNR).
The person I care for wears a state-prescribed out-of-hospital do not resuscitate (OOH DNR) medical alert bracelet.
The person I care for has a physician order for life-sustaining treatment (POLST) form.
Physician who entered the DNR:
Phone: Email:
Cell phone:
Physician who entered the OOH DNR:
Phone: Email:
Cell phone:
Physician who entered the POLST:
Phone: Email:
Cell phone:
The following health care facilities or providers have the medical orders:
Hospital:
Phone: Email:
Cell phone:
Hospital:
Phone: Email:
Cell phone:
Nursing facility:
Phone: Email:
Cell phone:
Assisted living facility:
Phone: Email:
Cell phone:
Health care agency:
Phone: Email:
Cell phone:
Other:
Phone: Email:
Cell phone: