Feel free to print this page to use as your Caregiver Action Plan! Co-Surviving Cancer, Katie Brown 2017-2019 ©
CAREGIVING ACTION PLAN
I. PERSONAL INFORMATION
Patient’s Name:_______________________________________________________
Street Address:_____________________________________________________
City, State, Zip:_________________________________________________________
Phone (home):__________________________ (cell):______________________
Email:_______________________________________________________
Primary and/or Emergency Contact(s)
_______________________________________________________________________
Nearest Neighbors/Friends
1. Name:________________________Email:________________________Phone:_____________
2.Name:________________________Email:________________________Phone:_____________
3. Name:_______________________Email:________________________Phone:_____________
Doctors/Specialists Phone Numbers
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nurse’s Line
____________________________________________________________
After Hours Hospital Line
____________________________________________________________
Pharmacy Address and Phone Number
____________________________________________________________
Accounts and passwords I should know: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CAREGIVING ACTION PLAN
II. Make a list of all medications, dosages and uses
CAREGIVING ACTION PLAN
III. TASK LIST (to be completed together with Patient)
WHO will help with healthcare tasks as needed such as:
__Attending medical appointments
__Asking questions of the medical team
__Researching treatment options and clinical trials
__Help with or arrange transportation to and from treatment
__Administering medications
__Monitor side effects
__Assisting with personal hygiene needs
__Physically assisting the patient when needed
__Reporting side effects to doctor
__Manage correspondence
WHO will help with household tasks as needed:
__Help or seek outside help for general household chores
__Help or seek outside help for general lawn care
__Help or seek help with grocery shopping and meal preparations
__Pay bills
WHO will help with legal and financial issues as needed:
__Help with insurance document and coverage issues
__Help with seeking financial assistance
__Help with employment issues
__Advance directives
__Living Will / Last Will and Testament
__Healthcare and Financial Power of Attorney
I cannot help with : ___________________________
____________________________________________
____________________________________________
____________________________________________
CAREGIVING ACTION PLAN
I. PERSONAL INFORMATION
Patient’s Name:_______________________________________________________
Street Address:_____________________________________________________
City, State, Zip:_________________________________________________________
Phone (home):__________________________ (cell):______________________
Email:_______________________________________________________
Primary and/or Emergency Contact(s)
_______________________________________________________________________
Nearest Neighbors/Friends
1. Name:________________________Email:________________________Phone:_____________
2.Name:________________________Email:________________________Phone:_____________
3. Name:_______________________Email:________________________Phone:_____________
Doctors/Specialists Phone Numbers
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nurse’s Line
____________________________________________________________
After Hours Hospital Line
____________________________________________________________
Pharmacy Address and Phone Number
____________________________________________________________
Accounts and passwords I should know: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CAREGIVING ACTION PLAN
II. Make a list of all medications, dosages and uses
CAREGIVING ACTION PLAN
III. TASK LIST (to be completed together with Patient)
WHO will help with healthcare tasks as needed such as:
__Attending medical appointments
__Asking questions of the medical team
__Researching treatment options and clinical trials
__Help with or arrange transportation to and from treatment
__Administering medications
__Monitor side effects
__Assisting with personal hygiene needs
__Physically assisting the patient when needed
__Reporting side effects to doctor
__Manage correspondence
WHO will help with household tasks as needed:
__Help or seek outside help for general household chores
__Help or seek outside help for general lawn care
__Help or seek help with grocery shopping and meal preparations
__Pay bills
WHO will help with legal and financial issues as needed:
__Help with insurance document and coverage issues
__Help with seeking financial assistance
__Help with employment issues
__Advance directives
__Living Will / Last Will and Testament
__Healthcare and Financial Power of Attorney
I cannot help with : ___________________________
____________________________________________
____________________________________________
____________________________________________
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