Free Dementia Emergency Binder Checklist

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1. Person Needing Care

Full Name

Date of Birth

Primary Phone

Address

Preferred Hospital

Pharmacy

2. Emergency Contacts

Primary Emergency Contact

Phone

Backup Emergency Contact

Phone

Healthcare Proxy Name

Healthcare Proxy Phone

Power of Attorney Name

Power of Attorney Phone

3. Doctors and Medical Providers

Primary Care Physician

PCP Phone

Neurologist

Neurologist Phone

Other Specialist

Specialist Phone

4. Medications, Diagnoses, and Allergies

Diagnosis / Conditions

Current Medications

Allergies

Recent Hospitalizations

5. Documents to Gather

Healthcare Proxy Power of Attorney MOLST / DNR if applicable Medicare, Medicaid, or health insurance cards Current medication list Photo ID Bank, bill, or benefit information needed by caregiver or POA

6. Dementia-Specific Notes

Wandering Risk / Triggers

Calming Techniques

Daily Routine

Foods, Activities, or Topics That Help

Behaviors to Watch For

Caregiver Instructions

7. Care Notes

Additional notes for family, caregivers, hospital staff, or case managers

1. Person Needing Care

2. Emergency Contacts

3. Doctors and Medical Providers

4. Medications, Diagnoses, and Allergies

5. Documents to Gather

6. Dementia-Specific Notes

7. Care Notes

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