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Print FormThe Caregiver’s NotebookA Guide for Organizing and Record Keeping307125WaverleyOaksStreet,Road Suite205 Waltham,MA0247202452WalnutWatertown,MA617-926-4100 www.springwell.com
Dear Caregiver,Welcome to the Springwell Caregiver’s Notebook!The goal of this Notebook is to have a central place for you to record anddocument the important aspects of your loved one’s care. This includes: Critical At A Glance InformationA Calendar for Schedule TrackingCare ProvidersDaily Routine and Care informationMedication InformationHealth Information and Medical EventsMedical Professional ContactsBecause it is easy to forget details from conversations and important nextsteps, we have included a Call Log section for tracking telephone calls andnotes from medical appointments.We have also included a section for legal, financial and insurance information.Since this information is confidential, we suggest the section be removed andstored in a safe place.The Notebook is intended to be comprehensive. Some sections may not beimmediately relevant. As you fill it in, it will help you be prepared when theneed for the information arises.Since information changes, use a pencil when filling out some of the forms(e.g., Medications). For your convenience, extra copies of the forms areavailable to download from our website, www.springwell.com.Our telephone number and website is included on every page. Please call uswith your questions and concerns. We are here to help you on your caregivingjourney.Questions? Call us at 617-926-4100 (TTY 617-923-1562) or visit us on the web:www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Making the most of this Organizational ToolThere is no question that filling out each line in this book can feel overwhelming. Because itwas designed to be a launching point for being a better informed and organized Caregiver, itcovers a wide range of information and details. Keep in mind you don’t need to complete everyline in each section. Use this as your framework for gathering and organizing information.Here are some tips on how to make the most of this Notebook: Pace yourself by choosing the pages and sections that are most relevant now, and startthere. As much as possible, involve your loved one in completing the information. It willprovide the opportunity for discussion and may also provide a sense of control during atime when control may seem fleeting to them. As with caregiving, don’t ‘go it alone’. Enlist family members and others close to theelder to help complete a page or an entire section. Since this tool is a 3 ring binder, you can customize it. Rearrange the sections to fit yourorganizational style. Decide which sections you want to have at the ready, whichsections should stay at the elder’s home and which sections should be removed to bestored in a safe place. To make certain pages portable, we suggest removing and storing them in a separate“travel” binder. Photocopy important papers to put into the binder while keeping the original in a safeplace. Use colored Post-It Note flags to alert a family member, friend or other caregiver on anyimportant changes or additions in the Notebook. Don’t limit the use of the Calendar to remembering medical appointments. Use it as atracking system for calls to make, medication changes, when a prescription needs to berefilled, etc. Gathering financial information can be a daunting task. Collecting one month’s worth ofmail will give you a snapshot of existing bills and financial statements (except for thosethat come quarterly). The most recent tax return is another good source of financialinformation. Remember, it is always best to ask permission to access any type offinancial records. Most importantly, use the Springwell Caregiver Program as your caregiving resource. ACaregiver Advisor can guide you on personalizing this tool to fit your caregiving needs.If you need suggestions on how to gather important information or broach a subject witha loved one, call us. A Caregiver Advisor is available to speak to in person as well as byphone and email to provide you with information and resources.Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Notebook ContentsSection 1 - At A GlanceCritical InformationEmergency Room ChecklistPerson(s) able to make Legal, Financial & Medical decisions in Elder’s SteadHome Emergency InformationImportant Personal ContactsMonthly Schedule Tracking CalendarSection 2 - Care ProvidersCaregiver InformationProfessional Service ProvidersAbout the ElderElder’s Self Care Abilities and NeedsDaily Activity LogSection 3 - MedicalMedication and Pharmacy InformationHealth LogMedical InformationImportant Medical EventsImportant TestsPhysicians and SpecialistsSection 4 - Call Log/Visit NotesCall LogUpcoming Doctor Visit NotesSection 5 - Legal, Financial and End of Life – Important InformationLocation of Key Documents and Important PapersLegal, Investment and Accounting ContactsInsurance (non-medical) Information and ContactsBanking InformationIncome, Expenses and Net WorthMonthly and Quarterly BillsEnd of Life InstructionsResources and NotesResourcesNotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Critical InformationNameDate of BirthAddressPhoneEmergency ContactNameRelationshipContact InstructionsHome PhWork PhCell PhNearest Relative, Friend/NeighborNameRelationshipContact InstructionsHome PhWork PhCell PhSpecial Health/Medical Conditions and InstructionsKnown AllergiesMedicationsFoodDietary RestrictionsDaily Fluid IntakeBaseline: Blood PressureBlood SugarWeightBlood TypeMedical CarePrimary Care DoctorPhone #HospitalPhone #Specialty DoctorPhone #Health InsurancePrimary PlanSupplementalID/Subscriber #ID/Subscriber #Phone #Phone #Declared Emergency Medical InstructionsInclude the name and location of any written documentation of emergency care wishes. For example, Physiciansigned Do Not Resuscitate (DNR) order, Health Care Proxy/Advanced Directive, or “File of Life”.Document NameLocationHealth Care AgentRelationshipContact #’s: HomeWorkCellOther Important InformationNote anything an outsider should be aware of including information about hearing, vision, memory, balance,walking, getting in/out of a chair or car, etc. If the elder has a Personal Emergency Response Service (i.e., Lifeline),note where the activation button is located.Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Emergency Room ChecklistItems to bring with you: Medical Insurance Cards List of telephone and contact information on all doctors and health care providers (Primary Care,Specialists, Home Health providers) List of all medications including over the counter, prescriptions and any supplements Assistive/Adaptive devices such as hearing aides, glasses, dentures, cane or walker Comfortable clothing (ideally without metal fasteners/zippers in case MRI or CT is needed),nightgown/pajamas, warm socks and slippers List of telephone numbers of close family members, friends and neighbors Other:Notify (family members, neighbors, friends):NameRelationshipHome #Work #Cell #NameRelationshipHome #Work #Cell #NameRelationshipHome #Work #Cell #NameRelationshipHome #Work #Cell #Services to suspend/cancel:Telephone # and/or WebsiteNewspaperMail deliveryMeal/Food deliveryIn Home ServicesCleaningHome Health CareOther:Other:Note: Check calendar to see if there are appointments that need to be canceledQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Person(s) able to make Medical, Legal and Financial Decisions in Elder’s SteadHealth Care Proxy/AgentPerson authorized to make decisions on medical treatment in the event of mental incapacityNameRelationshipAddressApt/Unit #StateZip CodeCityHome #Work #Email addressCell #Contact InstructionsDocument on file with Physician (s):Phone #NameNamePhone #Physician signed Do Not Resuscitate (DNR) Order on File? Yes NoDNR Order states there be no medical intervention to restore cardiac or respiratory function should either fail.Power of Attorney (POA)Durable? Yes NoPOA – Legal authorization to handle the personal and financial affairs of another.Durable POA- Remains in effect in the event of mental incapacity.NameAddressCityHome #Cell #Contact InstructionsDocument locationRelationshipApt/Unit #StateZip CodeWork #Email addressConservator or Representative PayeeConservator – Court appointed person to handle the financial affairs of one deemed mentally incompetent.Representative Payee – Person authorized to receive an elder’s Social Security check for bill paying purposes.NameAddressCityHome #Cell #Contact InstructionsDocument on file withRelationshipApt/Unit #StateZip CodeWork #Email addressGuardianCourt appointed person to handle the personal and financial matters of one deemed mentally incompetent.NameAddressCityHome #Cell #Contact InstructionsDocument on file withRelationshipApt/Unit #StateZip CodeWork #Email addressQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Home Emergency InformationAddressApt#Phone #LandlordPhone #Property ManagerPhone #Emergency ContactPhone #NeighborPhone #PoliceFireFire Extinguisher LocationAmbulanceFlashlightAlarm CompanyCode ClueSpecial InstructionsCircuit Breaker/Fuse Box LocationWater Valve Shut OffHome MaintenancePlumberPhone #ElectricianPhone #A/C HeatingPhone #Handy/Repair PersonPhone #Snow RemovalPhone #Gardener/LandscaperPhone #OtherPhone #ServiceElectricCompany NameUtility CompaniesPhone #Account ns? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Important Personal ContactsFor important correspondence, list important personal contacts such as relatives, neighbors, and friends(former classmates, co-workers, etc). “If something happened and you were in the hospital, who would youwant me to call?”NameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailNameRelationshipAddressCity, State & ZipHome #Work #Cell #EmailQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
urday Notes/To DoQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
Name:Date of Birth:Caregiver InformationPrimary CaregiverNameRelationshipAddressHome #Work #Cell #EmailVisits viaFrequency of visitsAssistance Provided: Personal Care MedicationSet upPrompting Meal Prep.Breakfast Lunch Shopping Transportation Medical Appointments Bill Paying/Money ManagementIn PersonOther Informal (unpaid) CaregiversNameRelationshipAddressHome #Work #Cell #EmailVisits viaIn PersonFrequency of visitsNameRelationshipAddressHome #Work #Cell #EmailVisits viaFrequency of visitsNameRelationshipAddressHome #Work #Cell #EmailVisits viaFrequency of visitsPhoneEmailAssistance Provided: Personal Care MedicationSet upPrompting Meal Prep.Breakfast Lunch Shopping Transportation Medical Appointments Bill Paying/Money ManagementPhonePhoneReligious/Cultural OrganizationNameAddressPhoneFrequency of visitsAssistance providedPhoneAdministrationDinnerEmailAssistance Provided: Personal Care MedicationSet upPrompting Meal Prep.Breakfast Lunch Shopping Transportation Medical Appointments Bill Paying/Money ManagementIn PersonAdministrationDinnerEmailAssistance Provided: Personal Care MedicationSet upPrompting Meal Prep.Breakfast Lunch Shopping Transportation Medical Appointments Bill Paying/Money ManagementIn lContactVisits In Person By PhoneQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Detailed Caregiver InformationNameAddressHome #Contact InstructionsRelationshipWork #Cell #EmailVisits viaHow Often In Person Phone EmailType of Assistance ProvidedPersonal CareFrequency of Assistance/Notes Bathing Dressing Grooming (hair, teeth) Walking/Mobility Lifting/Transferring Toileting EatingMedications Setting up pill box Prompting to take Helping to takeHousehold Management Meal Preparation Food Shopping Light Housework LaundryPersonal Management Transportation Shopping/Errands Medical Appointments Mail/Correspondence Banking/Bill PaymentHome Management Fix It/Repair Lawn Care Snow Removal Automobile CareOther AssistanceQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Professional Service ProvidersSkilled Nursing and Rehabilitation (Physical, Speech, Occupational) TherapiesAgency Namewww.AddressPhone #ContactDays/HrsAfter Hours ContactServiceFrequencyDays/TimesNamePaid for ByStart DateEnd DateStart DateEnd DatePersonal Care and Homemaking ServicesAgency Namewww.AddressPhone #ContactDays/HrsAfter Hours ContactServiceFrequencyDays/TimesNamePaid for ByOther Providers (Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)Agency Namewww.AddressPhone #ContactServiceFrequencyDays/TimesNameAgency NamePaid for ByStart DateEnd DateStart DateEnd Datewww.AddressPhone #ServiceContactFrequencyDays/TimesNamePaid for ByQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Other Providers (Emergency Response Service, Care Coordinator, Delivered Meals, Day Program, Transportation, etc.)Agency Namewww.AddressPhone #ContactServiceFrequencyDays/TimesNameAgency NamePaid for ByStart DateEnd DateStart DateEnd DateStart DateEnd DateStart DateEnd DateStart DateEnd Datewww.AddressPhone #ContactServiceFrequencyDays/TimesNameAgency NamePaid for Bywww.AddressPhone #ContactServiceFrequencyDays/TimesNameAgency NamePaid for Bywww.AddressPhone #ContactServiceFrequencyDays/TimesNameAgency NamePaid for Bywww.AddressPhone #ServiceContactFrequencyDays/TimesNamePaid for ByQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:About the ElderThe following is to help an outside caregiver learn about your loved one’s likes, dislikes and importantinformation about their life and day-to-day activities.Prefers to be called (Mr/Mrs/Miss, Nickname)First LanguageOther languages spokenImportant Social History (schooling, career, membership organizations, etc.)Important Relationships (close relatives and friends)NameRelationshipTownType and Frequency of contactEnjoys spending time by (social activities, etc.)Favorite places to go (restaurants, museums, parks, etc.)Favorite Pastimes (be as specific as possible and attach additional pages if necessary)HobbiesGamesSongs/MusicTV ShowsRadio StationTopics of interest (current events, sports, history, etc.)Food & Snack preferences and dislikesPet(s)NameFeeding InstructionsSpecial InstructionsDaily Routine OverviewWakes up atBreakfastMorning RoutineLunchAfternoon RoutineDinnerBefore BedBedtimeQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Elder’s Self-Care Abilities & NeedsDateAs you fill this out, think about whether you are comfortable with your loved one seeing your assessment oftheir abilities. If not, consider using it as an opportunity to discuss your concerns with them.Personal CareIndependentBathingDressingGrooming (hair, teeth)EatingWalking/MobilityToiletingMedications w/Assistance (Describe)Unable Household ManagementIndependentMeal PreparationFood ShoppingLight HouseworkLaundryTransportationMailBill/Money Management w/Assistance (Describe)Unable Adaptive Devices/EquipmentItemDescriptionGlassesHearing AidFalse Teeth/BridgeArm BraceLeg Supply Vendor InfoLeftRightPartial Upper LowerLeftRightLeftRightInserts ShoesStraightProngedw/ or w/o wheelsStandardElectricNotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Daily Activity LogUse this sheet to write down the day’s activities. This will help other caregivers, family members or visitorsknow specifics about the elder’s day such as what foods they ate, where they went, who called or visited.The notes can be brief or veningAbove notes written byQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:MEDICATIONS, OVER THE COUNTER AND DIETARY SUPPLEMENTS:Pill Boxes used? Yes No Person responsible for filling Pill BoxesWhere meds are keptNameSneeze AwayFormPillDosage1 50 mg 2x/dayForAllergiesBegan1/1/97EndM.D. & PharmacySmith/RexallNotesTake with gin IDPasswordAllergy InformationDrugReactionFirst OccurredQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.Treatment
Name:Date of Birth:Health LogDateTimeWeightBlood PressureBlood SugarNotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Medical InformationMedical DiagnosesDiagnosisDate givenDoctorTreatment/StatusSurgeries and ProceduresDateSurgeonHospitalComplications, if anyHospitalizations and Rehabilitation StaysDateHospitalReasonDischarge DateDischarged ToQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:DateDate of Birth:Important Medical Events (heart attack, seizure, fall, surgery, ER/Hospitalization, Rehab stay, etc.)EventTreating Physician Hospital/Facility AdmittedReasonDischargedNotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Important Tests (blood, CAT scan, X-Ray, MRI, etc)DateDescriptionOrdered ByPhone #Test ResultsQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.Results kept
NameDate of BirthPhysiciansPrimary CareNameAddressPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)Specialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)Specialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)Specialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved
NameDate of BirthAdditional Specialty PhysiciansSpecialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)NotesSpecialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)NotesSpecialty PhysicianStart DateEnd DateNameSpecialtyHospital/ClinicPhone #Pager #Days/HrsAfter Hours InstructionsFax #Email AddressHospital Affiliation (s)NotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved
NameDate of BirthOther Medical/Health ProfessionalsUse this page to note other health professionals such as Chiropractor, Dentist, Ophthalmologist,Optometrist, Audiologist, and Podiatrist. After their name, write the type of care they provide.NameAddressPhone #Fax #Days/HrsAfter Hours InstructionsPager #Web/Email AddressNameAddressPhone #Fax #Days/HrsAfter Hours InstructionsPager #Web/Email AddressNameAddressPhone #Fax #Days/HrsAfter Hours InstructionsPager #Web/Email AddressNameAddressPhone #Fax #Days/HrsAfter Hours InstructionsPager #Web/Email AddressNameAddressPhone #Fax #Days/HrsAfter Hours InstructionsPager #Web/Email AddressQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved
Name:Date of Birth:Call LogDate/Time Notes Spoke with, Agency Name, Phone#, What was discussedQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.To Do?
Name:Date of Birth:Upcoming Doctor VisitAppointment DateTimeDoctor’s NameSpecialtyOffice/Clinic LocationPhoneReason for visit (current symptoms)Remember to bring:Questions/Concerns to discussQ:A:Q:A:Q:A:Additional NotesTests DoneResults/Call for resultsOutcome - Diagnosis and Next StepsDiagnosisAdditional TestsTreatmentScheduled forWhat to ExpectMedication ChangesFollow Up Appointment Date and TimeRemember to bringOther Notes:Above notes written byQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Location of Key Documents - CONFIDENTIALDocumentSocial Security CardMedicare CardSecondary Health Insurance CardHealth Care ProxyLiving Will/Advance DirectivePower of AttorneyGuardianshipConservator/Representative PayeeLife Insurance Policy(s)WillTrust InformationMilitary ID/PapersReal Estate Property DeedsLocationDate NotedBank and other Financial DocumentsNote: Specify Name of Bank, Financial Institution or CompanyDocumentLocationDate NotedLoan DocumentsAnnuity ContractsStock Certificates/BondsBank Vault/Safe Deposit Box (es)Bank LocationBox #Location of KeyAdd’l Name/Signatures on fileBank LocationBox #Location of KeyAdd’l Name/Signatures on fileDateDateQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Legal, Investment and Accounting ContactsAttorneyNameFirm NameAddressOffice PhoneEmailOffice Hourswww.CityCell PhoneAssistant’s nameFinancial Advisor/PlannerNameFirm NameAddressOffice PhoneEmailOffice Hourswww.CityCell PhoneAssistant’s nameStock Broker/Investment ConsultantNameFirm NameAddressOffice PhoneEmailOffice HoursAccountant/Tax AdvisorNameFirm NameAddressOffice PhoneEmailOffice HoursOtherNameFirm NameAddressOffice PhoneEmailOffice Hourswww.CityCell PhoneAssistant’s namewww.CityCell PhoneAssistant’s namewww.CityCell PhoneAssistant’s ons? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:InsuranceHomePolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #AutomobileCar 1 MakePolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #Car 2 MakePolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #Phone tateZipwww.ModelYearPhone #www.Citywww.ModelYearPhone #www.Citywww.LifePolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #Phone #www.CityDisabilityPolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #Phone #www.CityLong Term CarePolicy#Agent NameAgency NameAddressInsurance Company/Underwriter24 Hour Claim Phone #Phone #www.Citywww.www.www.Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Banking Information - CONFIDENTIALBank NameAddressPhoneContact PersonEmail addressChecking Account #Savings Account #Money Market Account #On Line Banking WebsiteCertificates of DepositTermAmountBank NameAddressPhoneContact PersonEmail addressChecking Account #Savings Account #Money Market Account #On Line Banking WebsiteCertificates of DepositTermAmountBank NameAddressPhoneContact PersonEmail addressChecking Account #Savings Account #Money Market Account #On Line Banking WebsiteCertificates of DepositTermAmountwww.CityStateZipBranch where Acct was openedDirect lineBranch Days/HoursAdd’l Name on AcctAdd’l Name on AcctAdd’l Name on AcctUserIDPassword ClueStart DateMaturity DateNotes (auto rollover, etc.)www.CityStateZipBranch where Acct was openedDirect lineBranch Days/HoursAdd’l Name on AcctAdd’l Name on AcctAdd’l Name on AcctUserIDPassword ClueStart DateMaturity DateNotes (auto rollover, etc.)www.CityStateZipBranch where Acct was openedDirect lineBranch Days/HoursAdd’l Name on AcctAdd’l Name on AcctAdd’l Name on AcctUserIDPassword ClueStart DateMaturity DateNotes (auto rollover, etc.)Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Income, Expenses and Net Worth – CONFIDENTIALSocial Security #IncomeSocial dsRentOther:Other:TOTAL Assets (own)Checking AccountSavings AccountCD’sMoney Market FundsLife Insurance (cash value)Approximate Market Value ofPension FundsMutual FundsStocksU.S Treasury (bills, bonds)Real Estate EquityAutomobilesPersonal (Jewelry, Art, Furniture)Other (boat, etc)OtherTOTAL ExpensesRent/MortgageOther MortgageBank LoanIncome Tax (Qtrly)Property RestaurantsPersonal (hair, clothes)Auto (gas, repair)Other TransportationMedicalDentalHouse (landscaper, etc)In Home ServicesOtherOtherTOTAL Liabilities (owe)MortgageSecond MortgageReverse MortgageBank LoansCar LoansCredit CardsPersonal LoansOtherTOTAL Total AssetsMinus Total LiabilitiesTotal Assets Minus Total Liabilities NET WORTH Questions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:Monthly BillsExpenseRent/MortgageOther MortgageBank LoanCredit CardCredit CardCredit CardCredit CardGas/Auto Credit CardGas (house)OilElectricPhoneCellular PhoneTrash ount #Phone #Due DatePhone #Due DateNotesQuarterly BillsExpenseProperty TaxEstimated Income TaxWaterOtherOtherNameAccount #NotesQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
Name:Date of Birth:End of Life InstructionsEnd of Life discussions and decisions can be difficult. This page is to serve as a starting point in discussing andgathering the information. We encourage you to speak with the Primary Care Physician and call Springwell formore information and assistance with this complex topic. For detailed information on End of Life care and answersto frequently asked questions, go to www.endoflifecommission.org, or call 617-636-3480. To order a copy of “FiveWishes”, a document to put your wishes on specific treatment and care in writing, go to: www.agingwithdignity.orgor call 888-594-7437.Health Care Proxy/Advance Directive completed? YesNo On File with Dr.Includes the following requests: Do Not Hospitalize Do Not Resuscitate (revive heart or breathing) Do Not Tube Feed (insertion of tube into stomach to provide nutrition) Do Not Intubate(insertion of a tube to assist breathing) No Extraordinary Measures (any effort to artificially sustain life when no hope of medical improvement exists) Comfort Measures Only (no intervention to prevent death and make physically as comfortable as possible)Health Care AgentContact InstructionsHome #Family/Friend to be notifiedNameContact InstructionsHome #NameContact InstructionsHome #NameContact InstructionsHome #RelationshipWork #Cell #RelationshipWork #Cell #RelationshipWork #Cell #RelationshipWork #Cell #Attorney to be notifiedNameAddressPhone #Firm NameCityCell #Clergy to be notifiedNameAddressPhone #CityFuneral HomeAddressPhone #CemeteryAddressPhone #StateZipStateZipCity Pre-PaidStateZipCity Pre-Paid Lot#StateZipOther instructionsQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com 2008 Springwell, Inc. All Rights Reserved.
ResourcesSpringwell, Inc.125Walnut Street307 WaverleyOaks Road Suite 205Waltham, MAMA02452Watertown02472617-926-4100TTY: 617-923-1562Fax: caid - l Security ions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
NotesSpringwell, Inc.125WaverleyWalnut Street307Oaks Road Suite 205Waltham,MA02452Watertown MA02472617-926-4100TTY: 617-923-1562Fax: omQuestions? Call us at 617-926-4100 or visit us on the web: www.springwell.com
125 Walnut Street, Watertown, MA 02472 617-926-4100 www.springwell.com The Careg
