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Complete Care Plan form

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION ATLANTA, GA 30329 Complete care plan Complete THIS FORM with the information about the PERSON RECEIVING care A care plan summarizes a person s health conditions and current treatments for their care First Name: Date of birth: Age: Address: Last Name: Phone number: E-mail:About the person receiving care This information will help your caregivers to know you better and plan activities that you enjoy In a few sentences, tell people what you want them to know about you. What is your family like?

This document would be used together with the Living Will/Advanced Directive to guide your loved ones and your doctors in the event that you are unable to make your own decisions . The following documents will be attached to this Care Plan: Advanced Directive or Living Will;

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