Pre-Aging Agreement

Wishes/Issues

What are the most important wishes/issues facing your loved one(s) today and in the foreseeable future? The intent of this plan is to provide a basic template to best insure happiness, security, safety, and peace of mind for your parent(s), family members(s), or loved ones.

Living Situation

Evaluate current living situation

Potential future options

Drastic situation/change

Support Team

Primary caregiver

Support caregivers

Family members

Friends/Neighbors

Community

Church

Other organizations/clubs

Maintenance help e.g. landscaping, cook, and housekeeper

Pet care

Life alert/emergency response

 

*Include contact names, telephone numbers, e-mail addresses, and permanent addresses*

Medical Assessment

List of Physicians and Dentists

Physical therapist

Current Medications and Vitamins- List including name, dosage, reactions, and reason for taking

Allergies/other issues e.g. implant devices

Prescriptions- pharmacy, cost, and applicable insurance/ co-payments

Evaluate smoking/drinking habits

HIPAA rules

 

*Include contact names, telephone numbers, e-mail addresses, and permanent addresses*

Legal Documents

Birth information/date(s)- exact legal name(s)

Social Security number(s)

Bank Accounts- CD’s, Stocks, Bonds

Investments

Trusts

IRA & 401K

Life Insurance

Other insurance policies

Real Estate

Mortgage & property taxes

Identification- Birth Certificate, Social Security Card, Passport, and Driver’s Licenses

Credit card information

Will- Living Will, Advanced Directives, Power of Attorney, Medical Power of Attorney

Marriage documents

Divorce documents

Safety deposit box- location, keys, combinations

Citizenship papers

Business contracts

Legal agreements/documents

Property deeds

Titles

Location of Tax returns- Federal & State

 

*Include contact names, telephone numbers, e-mail addresses, and permanent addresses where applicable*

Financial Review

Finances

Insurance

Medicare/Medicaid

Veteran’s benefits

Pension

Social Security

Disability insurance

Property

Other income

Debts

Evaluate budget situation

Death & Dying

Life support

DNR (Do Not Resuscitate) orders

Organ donation

Final plans- burial or cremation

Final resting place, plans, and wishes

Financial arrangements

Review & Implement

TBD

 

Download this form here.

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