A Comprehensive Collection of Forms Including:Medical Information • Personal Contact Numbers • Emergency Information
Insurance Information • Care Giver’s Information •Organizational Tools
Record Keeping & Personal Care Guide
Why Keep Records 3
Personal Medical Information 4
Insurance Information 7
Community Resources Information 9
Care-Giver’s Guide 11
In Case of Emergency 18
Grocery List Template 21
Phone List Template 22
Personal Budget Worksheet 23
Table Of Contents
8 East Long Street,12th Floor Columbus, OH 43215
Telephone: 614-466-5205 Toll Free: 800-766-7426
TTY: 614-644-5530 FAX: 614-466-0298
www.ddc.ohio.gov
3
KEEPING VITAL RECORDS IS ESSENTIALNothing is more important to your personal welfare than developing and maintaining a complete, up-to-date record-keeping system.
Record-keeping is essential. It’s important for emergency hospital visits, insurance claims, respite care providers, or for documenting events and/or contacts about your medical needs. There is no other way to be prepared for events where current information is needed. Like it or not, understand it or not, there are forms you have to fill out everywhere you go! Having basic information on hand makes it manageable. It’s also a way of noting family history, developmental landmarks, and the next logical steps which may help identify delays or detect problems.
PERSONAL, MEDICAL & INSURANCE INFORMATIONBelow is a list of some of the important information that must be kept. It is not a complete list – that depends entirely on your disability or chronic illness. You may also decide to provide this information to other members of your family. This includes such personally identifiable information as:
Personal •Birthcertificates; •Parentorguardianinformation; •Locationofwillsand/ortrusts; •Dailycareschedule; •Grocerylist; •Budgetinformation; •Emergencycontacts;
Medical •Initialdiagnosis; •Healthhistory; •Physiciansandothermedicalspecialists; •Medicationandseizurelogs; •Dailycareschedule; •Immunizationrecords; •Officevisits; •Hospitalizationinformation; •Emergencycontacts;
Insurance •Healthandlifeinsuranceinformation;
MEDICAL BILLS & INSURANCE CLAIMSKeep all information needed to fill out forms. Keep a supply of blank claim forms, envelopes and stamps. Maintain files on all insurance company correspondence or claims. For tax purposes, keep an accurate account of what your policy covered and your out-of-pocket expenses.
EVALUATIONS, REPORTS & RECORDSKeep copies or records of all correspondence (written and verbal) with service providers, medical support specialists and other professionals your child comes in contact with, along with all reports, records and other documents. They may contain important information in those cases where discrepancies may arise concerning your needs and/or program. Be certain copies of all medical reports are sent to your physician.
GETTING ORGANIZEDHowyourrecord-keepingsystemisorganizedisuptoyou.Justbecertainitallowsquick,easyaccesstoalltheinformation needed under any set of circumstance. Here are some recommendations. Purchase a three-ring binder with pocketsfororganizingandholdingreports,etc.Insertblankpagesand/orformsforrecordingyourowninformation.Keepall current information in the notebook. Keep older information in a permanent, but portable, filing system. Purchase a small, portable file and file folders. File information using separate file folders for each category. To prevent record keeping from becomingachorethatkeepsyoufromspendingtimewiththeimportantpeopleinyourlife,organizeearlyandinamannerthat best suits your individual needs.
4
Personal Medical Information
Name Age DateofBirth
Birthplace Sex (M ) (F ) Social Security Number
Address City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Father/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Mother/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Per
son
al I
nfo
rm
atio
n
InitialDiagnosis
DiagnosisDate
Other Medical Conditions/Information
Allergies
Medications
AssistiveDevices
Eyeand/orHearingDevices
Family Physician
Office Address
City State Zip
Office Telephone ( )
Other Medical Specialist
Office Address
City State Zip
Office Telephone ( )
Other Medical Specialist
Office Address
City State Zip
Office Telephone ( )
Other Medical Specialist
Office Address
City State Zip
Office Telephone ( )
Hea
lth
His
tor
y
Today’sDate
5
Tes
ts &
Eva
luat
ion
s
Med
ical
Off
ice
Vis
itsConducted By
Office Telephone
DateConducted
Test/Evaluation Result
Conducted By
Office Telephone
DateConducted
Test/Evaluation Result
Conducted By
Office Telephone
DateConducted
Test/Evaluation Result
Conducted By
Office Telephone
DateConducted
Test/Evaluation Result
Conducted By
Office Telephone
DateConducted
Test/Evaluation Result
Date
Reason for Visit
Physician/Specialist
Clinic Name
Office Telephone
Test Performed
Results & Treatment
Follow-Up Instructions
Notes
Date
Reason for Visit
Physician/Specialist
Clinic Name
Office Telephone
Test Performed
Results & Treatment
Follow-Up Instructions
Notes
Date
Reason for Visit
Physician/Specialist
Clinic Name
Office Telephone
Test Performed
Results & Treatment
Follow-Up Instructions
Notes
6
Med
icat
ion
Rec
or
ds
Date Prescribed or Changed
MedicationDoseage &
Times Per DayDoctor’s Special
InstructionsSide Effectsor Concerns
DateDiscontinued
ReasonDiscontinued
7
Insurance Information
Name Age DateofBirth
Birthplace Sex (M ) (F ) Social Security Number
Address City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Father/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Mother/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Per
son
al I
nfo
rm
atio
n
Today’sDate
Primary Insurance Carrier
Office Address City State Zip
Office Telephone ( ) Policy Number Group Number
Agent’s Name
Agent’s Address City State Zip
Office Telephone ( )
Secondary Insurance Carrier
Office Address City State Zip
Office Telephone ( ) Policy Number Group Number
Agent’s Name
Agent’s Address City State Zip
Office Telephone ( )
MedicaidNumber State DateofEligibility
Insu
ran
ce
Co
mpa
ny
Info
rm
atio
n
8
Po
lic
yho
lder Name
Address City State Zip
Home Telephone ( ) Cell Phone ( )
DateofBirth SocialSecurityNumber
Fam
ily
Mem
ber
s Name Relationship to Policyholder
DateofBirth SocialSecurityNumber
Name Relationship to Policyholder
DateofBirth SocialSecurityNumber
Name Relationship to Policyholder
DateofBirth SocialSecurityNumber
Oth
er I
mpo
rtan
t In
for
mat
ion Pre-existing conditions not covered, waivers or riders attached to the policy, cost-share information, etc.
9
Community Resources Information
Name Age DateofBirth
Birthplace Sex (M ) (F ) Social Security Number
Address City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Father/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Mother/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Per
son
al I
nfo
rm
atio
n
Today’sDate
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
Co
mm
un
ity
Serv
ices
(N
on
pro
fit)
10
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
Co
un
ty
Serv
ices
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
Oth
er A
gen
cy/
Or
gan
izat
ion
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
NameofAgency/Organization
Office Address City State Zip
Office Telephone ( ) Contact Person
DescriptionofServices
Stat
e A
gen
cy/
Or
gan
izat
ion
11
Care-Giver’s Guide
Child’sName Age DateofBirth
Birthplace Sex (M ) (F ) Social Security Number
Address City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Father/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Mother/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Per
son
al I
nfo
rm
atio
n
Today’sDate
Police, Fire & Ambulance – 911Poison Control Center Telephone ( )
Family Physician Telephone ( )
Pharmacy Telephone ( )
Insurance Agency
Contact Person Telephone ( )
Preferred Hospital Telephone ( )
Neighbor Telephone ( )
Neighbor Telephone ( )
Relative or Close Friend
Relationship Telephone ( )
Relative or Close Friend
Relationship Telephone ( )
Emer
gen
cy
Co
nta
cts
/Nu
mbe
rs
12
First aid kit location
Who, if anyone is allowed to visit the child when the parent isn’t home?
Is the child allowed to play outside? (Yes) (No)
If so, explain the boundaries, rules and length of time
Household rules providers and caregivers should follow when the parents are not home
Ho
use
ho
ld R
ou
tin
e
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
Ch
ild
’s D
aily
Sc
hed
ule
13
ChildDiagnosedWith
Other Medical Conditions/Information
Family Physician
Office Address City State Zip
Office Telephone ( )
Allergies
Ch
ild
’s M
edic
al I
nfo
rm
atio
nC
hil
d’s
Med
icat
ion
s
Medication Doseage Time(s) GivenPrescribing
DoctorEmergencyTelephone
14
Doesthechildhaveseizures?(Yes)(No)
If so, describe in detail
Generallengthofseizures
Whatprocedure(s)shouldbefollowedduringaseizure?(Doyouwanttheparamedicstobecalled?)
Shouldseizuresberecorded?(Yes)(No)
Whatusuallyoccursfollowingaseizure?(Willthechildbecomesleepy,cranky,etc.)
Seiz
ur
es
Describethechild’snormalbehavior
Are there behaviors that are particularly challenging?
If so, what actions should be taken?
Is there a specific behavior plan for the child? If so, please describe
Has the child been known to wander or run away?
Activities that make the child happy, including toys, favorite games, etc.
Notes
Ch
ild
’s B
ehav
ior
15
Is the child verbal? (Yes) (No)
In case the child isn’t verbal, how does he or she communicate?
Specifically, how does the child communicate the need to eat?
Ask to be picked up or held?
Express interest in playing with a specific toy or game?
Doesthechildusesignlanguageasaformofcommunication?(Yes)(No)
If so, please explain how
How does the child communicate the following?
Co
mm
un
icat
ing
Wit
h T
he
Ch
ild
Hungry
Thirsty
Tired
Happy
Hot
Cold
Brother
Sister
Mother
Father
Blanket
Bath
Toilet
Diaper
Bed
Dog
Cat
Video
TV
Music
Hello
Goodbye
Car
Walk
Outside
Inside
Sad
Angry
Play with me
Leave me alone
I want more
I am finished
Please
Thank you
I’m sick
Other
16
Doesthechilduseaspecializedcommunicationdevice?(Yes)(No)
If so, explain how the device is used
Where is it located and/or placed when not in use?
Co
nt.
..
Are there foods the child likes?
Are there foods the child dislikes?
Doesthechildhaveanyfoodallergies?Ifso,pleaselistandidentifysymptoms
Doesthechildswallowwell?(Yes)(No)Pleaseexplain
Doesthechildneedassistancewhileeating?(Yes)(No)Ifyes,whattypeofassistanceisnecessary?
Isthereaparticularpositionoradaptiveequipmentnecessarytoassistthechildduringthemeal?
Pleasedetailthelocationofthechild’sfood,eatingutensilsand/oradaptiveequipment
Ch
ild
’s D
iet
At what time does the child go to bed?
What are the child’s nap time(s)?
Doesthechildsleepalone?(Yes)(No)
Is the child afraid of the dark? (Yes) (No)
Is there a special toy or blanket the child likes to sleep with?
Are there special positioning needs at bed time?
Is any special nightly routine observed?
Doesthechildusuallysleepthroughthenight?(Yes)(No)Ifnot,explaintheactivitiesrequiredtoeitherinducesleeporkeep
the child occupied while awake.
Ch
ild
’s B
ed &
Nap
Tim
es
17
Doesthechildusethetoilet?(Yes)(No)
Can he or she use the toilet alone? (Yes) (No)
Ifnot,describethespecialassistancerequired
Doesthechildrequirediapers?(Yes)(No)
Training Pants (Yes) (No)
Use a potty chair? (Yes) (No)
Can the child brush his or her own teeth? (Yes) (No)
If yes, explain how
Can the child dress himself or herself? (Yes) (No)
If yes, what assistance is necessary?
Can the child bathe himself or herself? (Yes) (No)
Isadaptiveequipmentrequired?(Yes)(No)
Ifyes,explainhowtheequipmentisused
Per
son
al H
ygie
ne
Doesthechilduseadaptiveequipment?(Yes)(No)
Describetheequipmentandhowitshouldbeused
Ad
apti
ve/
Ass
isti
ve
Equ
ipm
ent
18
In Case Of Emergency
Child’sName Age DateofBirth
Birthplace Sex (M ) (F ) Social Security Number
Address City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Height Weight
Hair Color Eye Color
DistinguishingMarks
Per
son
al I
nfo
rm
atio
n
Father/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Mother/Legal Guardian Social Security Number
Address (if different) City State Zip
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Primary Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Today’sDate
Emer
gen
cy
Co
nta
ct
Nu
mbe
rs
Secondary Emergency Contact Relationship
Home Telephone ( ) Work Telephone ( ) Cell Phone ( )
Primary Physician
Office Telephone ( ) Emergency Telephone ( )
Notes
Secondary Physician
Office Telephone ( ) Emergency Telephone ( )
Notes
What I want an emergency physician to know
19
Pres
cr
ipti
on
Dr
ug
sA
ller
gie
sC
hr
on
ic C
on
dit
ion
sMedication Doseage Frequency Reason
Type Severity Frequency/Last Occurrence
Type Severity Notes
20
Primary Insurance Carrier
Office Address City State Zip
Office Telephone ( ) Policy Number Group Number
Agent’s Name
Agent’s Address City State Zip
Office Telephone ( )
Secondary Insurance Carrier
Office Address City State Zip
Office Telephone ( ) Policy Number Group Number
Agent’s Name
Agent’s Address City State Zip
Office Telephone ( )
MedicaidNumber State DateofEligibility
Insu
ran
ce
Info
rm
atio
nN
ote
s
21
Grocery List
Make grocery shopping easier by always going with a prepared list. The following template can be copied and used again and again.
ProducePotatoesMushroomsOnionsLettuceTomatoCarrotsBroccoliCauliflowerSpinachBananasApplesOrangesGrapesMelonBerriesLemon/Lime__________________
DeliDeliMeatsDeliSaladsDeliCheese__________________
SnacksCookiesCrackersGraham CrackersChipsPopcorn__________________
BreadsBreadHotDogBunsHamburger BunsBagelsEnglish MuffinsCroutons__________________
BeveragesJuiceKool AidLemonadePop/SodaBottled WaterChocolate SyrupCoffeeTea__________________
CondimentsBBQ SauceMustardMayonnaisePickles/RelishKetchupMarinadeSaladDressingsJelly/JamPeanut ButterSeasoning Packet__________________
Canned GoodsTunaSpaghetti SaucePizzaSauceTomato ProductsMushroomsSoupBeansCorn__________________
Canned FruitsApplesauceFruit CupsPineapplePeachesPearsFruit CocktailRaisins__________________
BakeryDonutsCakePieCinnamon RollsBrowniesCookies__________________
DairyMilkOrangeJuiceDinnerRollDoughCookieDoughButter/MargarineEggsYogurtSliced/Shredded CheeseCream CheeseSour CreamCottage Cheese__________________
CerealsCerealGranola BarsOatmealHot Cereal__________________
PastaSpaghettiMac & CheeseLasagna NoodlesRiceNoodle & Sauce Mix__________________
Ethnic FoodsTaco MixTortilla ShellsTaco SauceSoy SauceTeriyaki Sauce__________________
MeatGround BeefChickenGround TurkeyBeef RoastSteaksBurger PattiesPork ChopsPork RoastBaconHotDogsSausageBratsHam__________________
BakingSugarFlourPancake MixMuffin MixCake/Brownie MixPie CrustMarshmallowsJelloPuddingPancake SyrupHoneyChocolate Chips__________________
Health/BeautySuntan lotionShampooConditionerDeodorantBath SoapFeminine SuppliesMake-UpToothpasteMouthwashLotionBand AidsAntiseptic CreamMedicinesVitamins__________________
Frozen FoodsFrozenMeatsFrozenVeggiesFrozenFruitsWafflesFrench FriesPizzaIce Cream__________________
Paper GoodsNapkinsPaper TowelsToilet PaperTissuesPaper PlatesPaper CupsPlastic BagsAluminum FoilPlastic WrapWax Paper__________________
CleanersLaundryDetergentFabric SoftenerDishwasherSoapBleachDisinfectantDustingSpray__________________
Baby ItemsBaby FoodDiapersBaby Wipes__________________
OtherPet FoodLight BulbsCards/Gift Wrap__________________
22
Phone List
My Home Telephone
My Cell Phone
Mother/Guardian
Father/Guardian
Primary Physician
Secondary Physician
Dentist
Optometrist
Neighbor
Neighbor
Babysitter
Impo
rtan
t Ph
on
e N
um
ber
s
23
Personal Budget Worksheet
Income Monthly Amount
Net Pay
SecondJob-NetPay
Investments
Interest
Other
TOTAL INCOME $ .
Inc
om
e
Expense Monthly Amount
Cable TV
Car Payments
Child Care
Credit Card Payments
Insurance (Health, Life, Property)
Internet Service Provider
Rent or Mortgage
Student Loans
Taxes
Telephone
Utilities
Other
TOTAL ROUTINE EXPENSES $ .
Ro
uti
ne
(Fix
ed)
Exp
ense
s
Expense Monthly Amount
Babysitting
Food
Transportation (Gas, Maintenance, Parking, Taxis)
Vacation
Clothing(Purchases,DryCleaning)
Education
Entertainment
Gifts (Birthdays, Holidays, Weddings)
Hair Care, Body Care (Hair Cuts, Manicures, Tanning)
Medication, Medical Visits, Glasses/Contacts
Savings
Other
TOTAL VARIABLE EXPENSES $ .
Var
iabl
e Exp
ense
s
Total monthly fixed and variable expenses $ . Differencebetweenmonthlyincomeandexpenses=surplus/(deficit) $.
It is the mission of the Ohio Developmental Disabilities Council to create change that improves independence, productivity, and inclusion for people
with developmental disabilities and their families in community life.
www.ddc.ohio.gov
Top Related