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The Form that Older Adults Need to have with them in the Hospital to Save Time, Money, and Stress

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Or keep reading if you need more convincing 😉

I dream of a day when there is a universal intake form that we all fill out at any hospital, rehab facility, doctor’s visit, etc.  It will be kept safely where it can be accessed as needed by the individual who filled it out and any of their healthcare providers without the need for going through the same questions over and over and without any miscommunication between healthcare workers.  Unfortunately, that day has not come yet.  In the meantime, I’ve taken the liberty of creating my own and I’d love to share it with you.

 What does this form include?

General information about you

Emergency contact information

Primary language spoken

A simple, but inclusive medical history

Dietary guidelines


Blank spaces to fill in as needed

A medication list

Your home setup (for example:  do you live alone, have stairs to enter your house, etc?)

What you can typically do for yourself (walk, dress yourself, drive…)

What aides do you use at home (ex: walker, ankle brace, supplemental oxygen, etc.)


Why is this important?

  • In emergency situations, there is often not time to fill out the appropriate intake information before important medical decisions must be made.


  • It’s imperative that you always have an updated medication list for many reasons
    • To allow your doctor or pharmacist to inspect your medication list for possible drug interactions and side effects
    • To make sure that you can get all your needed medications refilled in the event of an emergency such as a fire or natural disaster
    • To provide your medication list at all your doctor appointments and hospital visits.
    • To allow your medical team to make the right treatment decisions in emergency situations


  • These days medical care is so specialized that we often see dozens of doctors and other medical professionals in a given year, and it is important that they are all receiving updated, accurate information


  • Unless patients have a perfectly competent loved one with them 24 hours/day when in the hospital, there are often communication issues between the patient and the medical team. Communication barriers could be caused by:
    • The patient has difficulty hearing
    • The patient does not speak English
    • The patient is confused, drowsy, in a coma, etc.
    • The patient is frustrated and unwilling to keep answering the same questions over and over
    • The medical team doesn’t get a thorough history before making medical decisions
    • The medical team overlooks an important factor such as a food or medication allergy


  • Without accurate information about the patient’s prior level, they may end up getting sent home from the hospital too soon OR they may have to stay longer than needed.
    • For example: Imagine that David is a 70 year old man hospitalized after a bout of pneumonia.  He is divorced and lives alone.  His daughter has been checking in on him daily while in the hospital and she will be driving him home, but then David will be on his own.  For the last 2 days he has been walking around his hospital room without any assistance so the doctors are ready to send him home today.  No physical therapy was ordered in the hospital since David had been maneuvering in his room independently.  However, it turns out that David is going to have to use an oxygen tank for his breathing when he goes home (which he’s never had to do before,) and he has a flight of stairs to climb in order to reach his 2nd floor apartment.  If these pieces of information were known at the beginning of the hospital stay then physical therapy probably would have started working with David right away and preparing him for a safe return home.  Now he’s going to be stuck in the hospital for an extra 1-2 days in order to make arrangements with the oxygen supply company as well as to practice walking longer distances and going up and down a flight of stairs while safely managing oxygen tubing.

You need this form….and so do your loved ones!

As you can see, there any many reasons to keep an updated form regarding medical history, medications, and your prior level of activity/home setup.  At the very least, you should have an updated list of medications with you at all times.  This could be as simple as keeping a piece of paper in your wallet or purse, keeping a photo of it on your smart phone, and/or emailing it to yourself.  Keep the original somewhere in your home where you can easily access it at any time to update it and replace the copy in your purse or wallet, on your smart phone, and in your email.  The form that I’ve created for you is a total of 3 pages (one whole page is for the medication list only), though it is very simple and easy to work through quickly.  Fill it out, keep it updated, and do your best to have it with you or at least keep it in a place that any of your loved ones could grab it for you on a moment’s notice and then post it somewhere in your hospital room for the whole healthcare team to browse through.  It could save you thousands of dollars, days in the hospital (or help qualify you for more medical care if needed), and a whole lot of stress for yourself and your loved ones.

Click here to get it, for FREE!


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