Clover's Group

Quick-Start Binder

Faith · Hope · Love · God's Grace

Last updated: ____________

The Clovers Group

Quick-Start Binder

The most important information for appointments, emergencies, medications, and safer care.

3 guides · 9 pages

CLOVER’S GROUP

Faith · Hope · Love · God’s Grace

1. Essential Care Information

Identity, emergency info, family and providers — everything the whole team needs.

Care recipient & caregiver

page 1 / 3

Identity

Preferred name

Legal name

Date of birth

Home address

Phone

Primary language

Preferred hospital

Health & care needs

Primary diagnoses

Allergies

Mobility needs

Communication needs

Cognitive or behavioral considerations

Dietary needs

Faith or spiritual preferences

Primary caregiver

Caregiver's name

Relationship

Last updated

Emergency & household

page 2 / 3

Emergency call

Contact 1 — name

Contact 1 — relationship

Contact 1 — phone

Contact 2 — name

Contact 2 — relationship

Contact 2 — phone

Medical essentials

Current diagnoses

Critical medications (with doses)

Advance directive / code status is kept at

Primary insurance

Primary physician

Physician phone

Pharmacy

Pharmacy phone

Home & household

Evacuation plan

Pets or dependents needing care

Important instructions

Contacts & providers

page 3 / 3

Family, medical, community contacts

Contacts

Contact 1

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Medical providers

Providers

Provider 1

Provider name

Specialty

Practice

Phone

Fax

Portal or website

Address

After-hours instructions

Referral requirements

Next visit

Notes

2. Medications and Health

The medication picture, seven-day log, symptom tracker, and questions for the care team.

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

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.

Doses

Dose 1

Date

Scheduled time

Medication

Dose

Given time

Initials

Skipped / refused

Reason (if skipped)

Notes

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

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

Quick-Start Binder

1. Essential Care Information

Care recipient & caregiver

Identity

Health & care needs

Primary caregiver

Emergency & household

Emergency call

Medical essentials

Home & household

Contacts & providers

Family, medical, community contacts

Contact 1

Medical providers

Provider 1

2. Medications and Health

Allergies & current medications

Allergies & reactions

Current medications

Medication 1

Seven-day medication log (refill)

Dose 1

Symptom log & questions for the care team (refill)

Symptom observations

Observation 1

Priority questions

Question 1

3. Home, Fall and Hospital Safety

Mobility & home safety

Assistive devices

Transfer plan

Recent falls

Room-by-room safety

Hospital / ER go-bag

Documents

Everyday essentials

Home & pets

Hospital discharge checklist

Understanding the situation

Medications

Follow-up + equipment

Concerns before discharge