Free Caregiver Care Plan

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I. Introduction

Welcome to the Caregiver Care Plan designed to provide comprehensive support and guidance for caregivers tasked with assisting individuals with diverse healthcare needs. This personalized plan serves as a roadmap, outlining essential information, strategies, and resources to ensure the well-being and safety of both the caregiver and the individual under their care.

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II. Personal Information

Name: [Your Name]

Age: [Patient's Age]

Gender: [Patient's Gender]

Medical History: [Medical Conditions]

Contact Information

Address: [Your Address]

Email: [Patient's Email Address]

Emergency Contacts

• [Primary Emergency Contact Name] - [Primary Emergency Contact Phone Number]

• [Secondary Emergency Contact Name] - [Secondary Emergency Contact Phone Number]

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III. Medical Needs

Diagnosis: Dementia

Medications:

• Donepezil (Aricept) - 10mg daily

• Metformin - 1000mg twice daily

• Lisinopril - 20mg once daily

Allergies: None

Dietary Restrictions: Low sodium diet

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IV Activities of Daily Living (ADLs)

Bathing

• Requires assistance, and prefers showers.

Dressing

• Partial assistance is needed, selects clothes independently.

Grooming

• Minimal assistance is required and needs reminders to brush their teeth.

Eating

• Independent but requires supervision due to forgetfulness.

Mobility

• Uses a walker, and needs assistance with stairs.

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V. Emotional Support

• Responds well to familiar routines and soothing music.

• Engage in reminiscence activities to stimulate memory.

• Encourage participation in light exercises and social interactions.

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VI. Safety Measures

• Remove tripping hazards and install grab bars in the bathroom.

• Ensure medication compliance with a pill organizer.

• Keep emergency numbers posted near the phone and programmed into speed dial.

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VII. Care Schedule

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VIII. Contact Information

Primary Care Physician: [Physician's Name]

Phone: [Physician's Phone Number]

Specialist: [Specialist's Name]

Phone: [Specialist's Phone Number]

Home Health Agency: [Agency Name]

Phone: [Agency Phone Number]

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IX. Emergency Plans

• In case of a medical emergency, call 911.

• Notify the primary contact immediately.

• Keep a copy of the Caregiver Care Plan readily accessible for emergency responders.

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Plan Templates @ Template.net