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Index

Return this book to:

Emergency Information

Personal Information

Daily Schedule

Medications

Project Plan

Daily Meal Planner

Telephone Numbers

Photos of Important People

 

Return this book to:

Name:____________________

Address:__________________

__________________________

__________________________

Phone:____________________

 

 

Emergency Information

Phone Numbers

Emergency:_______________

Doctor:___________________

Pharmacy:________________

Family:___________________

 

My Address is:

____________________________

____________________________

____________________________

My Phone Number is:

____________________________

 

Personal Information

Name:___________________________________________

Address:_________________________________________

_________________________________________________

Phone number:____________________________________

Age:_____________________________________________

Date of birth:______________________________________

Father's name:____________________________________

Mother's age:_____________________________________

Husband's/Wife's name:____________________________

Year you were married:_____________________________

Names of children:________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

Names of grandchildren:       Parents

_______________________   ____________   ___________

_______________________   ____________   ___________

_______________________   ____________   ___________

_______________________   ____________   ___________

_______________________   ____________   ___________

Brothers' names

________________________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

Sisters' names

________________________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

________________________________ Age:____________

Educational Background:

School                                               Dates attended

__________________________  _____________________

__________________________  _____________________

__________________________  _____________________

Work History:

Place of employment                      Dates employed

__________________________  _____________________

__________________________  _____________________

__________________________  _____________________

__________________________  _____________________

__________________________  _____________________

 

Hobbies:

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

 

 

Daily Schedule

Today's Date:______________

Day of the week:______________

_________________________________

_________________________________

_________________________________

____________________

_________________________________

_________________________________

_________________________________

____________________

_________________________________

_________________________________

_________________________________

____________________

_________________________________

_________________________________

_________________________________

____________________

 

 

Medications

Name of Medication      Reason for taking              Dosage

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

_________________     ____________________  ________

If the following symptoms occur, call the doctor:

Doctor's Number:________________

________________________________________________

________________________________________________

________________________________________________

 

Project Plan

Project:__________________________________

Things to purchase:_______________________

_________________________________________

_________________________________________

Things to gather:__________________________

_________________________________________

_________________________________________

Steps to complete task:

1._______________________________________

2._______________________________________

3._______________________________________

4._______________________________________

5._______________________________________

6._______________________________________

7._______________________________________

8._______________________________________

 

Daily Meal Planner

Day of the week_______  Date________

Breakfast Menu       Steps to complete the meal

_______________   1.______________________

_______________   2.______________________

_______________   3.______________________

_______________   4.______________________

_______________   5.______________________

_______________   6.______________________

_______________   7.______________________

_______________   8.______________________

 

Lunch Menu            Steps to complete the meal

_______________   1.______________________

_______________   2.______________________

_______________   3.______________________

_______________   4.______________________

_______________   5.______________________

_______________   6.______________________

_______________   7.______________________

_______________   8.______________________

 

Dinner Menu           Steps to complete the meal

_______________   1.______________________

_______________   2.______________________

_______________   3.______________________

_______________   4.______________________

_______________   5.______________________

_______________   6.______________________

_______________   7.______________________

_______________   8.______________________

 

 

Telephone Numbers

Name:__________________________________

Address:________________________________

________________________________________

Phone Number:__________________________

 

Name:__________________________________

Address:________________________________

________________________________________

Phone Number:__________________________

 

Name:__________________________________

Address:________________________________

________________________________________

Phone Number:__________________________

 

 

Photos of Important People

 

 

(attach photo here...)

 

 

 

 

 

Name:_________________________________

Title:__________________________________

Describe the meaning of this picture:______________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________