Clover Care Navigator | Clover's Group — Caregiver Guidance and Local Resources

Allergies & current medications

page 1 / 3

Allergies & reactions

Known allergies

Adverse reactions / medications to avoid

Current medications

Medications

Medication 1

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Medication 2

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Medication 3

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Medication 4

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Medication 5

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Medication 6

Medication

Strength (e.g. 10 mg)

Dose (e.g. 1 tablet)

Route (oral, topical, injection, etc.)

Time / frequency

Purpose

Prescribing provider

Start date

Pharmacy

Next refill

Special instructions

Seven-day medication log (refill)

page 2 / 3

Bring a fresh copy to every appointment. Do not change medication without guidance from the appropriate licensed clinician.

Symptom log & questions for the care team (refill)

page 3 / 3

Symptom observations

Observations

Observation 1

Date

Time

Symptom or change observed

Severity (0 none – 10 severe)

Duration

Possible trigger

Action taken

Response

Temperature

Blood pressure

Pulse

Oxygen (if used)

Blood sugar (if used)

Clinician contacted

Instructions received

Observation 2

Date

Time

Symptom or change observed

Severity (0 none – 10 severe)

Duration

Possible trigger

Action taken

Response

Temperature

Blood pressure

Pulse

Oxygen (if used)

Blood sugar (if used)

Clinician contacted

Instructions received

Observation 3

Date

Time

Symptom or change observed

Severity (0 none – 10 severe)

Duration

Possible trigger

Action taken

Response

Temperature

Blood pressure

Pulse

Oxygen (if used)

Blood sugar (if used)

Clinician contacted

Instructions received

Observation 4

Date

Time

Symptom or change observed

Severity (0 none – 10 severe)

Duration

Possible trigger

Action taken

Response

Temperature

Blood pressure

Pulse

Oxygen (if used)

Blood sugar (if used)

Clinician contacted

Instructions received

Priority questions

Questions

Question 1

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed

Question 2

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed

Question 3

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed

Question 4

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed

Question 5

Topic (condition, medication, safety, therapy, nutrition, behavior, care setting, insurance, future, family)

My question

Answer

Who answered

Date

Follow-up needed

Medications and Health

Allergies & current medications

Allergies & reactions

Current medications

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Seven-day medication log (refill)

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

Dose 7

Dose 8

Dose 9

Dose 10

Dose 11

Dose 12

Symptom log & questions for the care team (refill)

Symptom observations

Observation 1

Observation 2

Observation 3

Observation 4

Priority questions

Question 1

Question 2

Question 3

Question 4

Question 5