EverGuide Client Snapshot

Date and time

Month

Day

Year

Time

HoursMinutes

Facilitator

Location

PERSONAL PROFILE

First name

Last name

Address

Phone

Birthday

Month

Day

Year

Are You A Medicare Recipient?

Medicare Number

Supplemental Insurance

Supplemental Number

Who was present at meeting

Do you have a legal Patient Advocate or Medical Power of Attorney?

Advocate Name & Relationship

WELL-BEING OVERVIEW

What Matters Most

When you think about your life right now, what matters most to you?

What’s most important for you to be able to keep doing, enjoying, or experiencing?

If you could change anything about your day to day living, what would it be?

Mood

How have your spirits been these days?

Do you feel you’ve been staying connected with people who matter to you?

Memory

Have you noticed yourself forgetting things more often lately?

Are there times when you feel a little foggy or not quite as sharp as usual?

Meaning

Are there things that still feel meaningful or important to you, even in the midst of all this?

Are there parts of your day or week that bring you a sense of joy, comfort, or connection?

Mobility & Safety

How are you getting around these days?

Do you feel steady on your feet, or do you ever worry about falling?

Have you had to cut back on any activities because of your balance, strength, or stamina?

Medications

Are you able to manage your medications easily?

Have there been any mix-ups, missed doses, or changes recently?

Life Enjoyment

What do you still enjoy or look forward t in your day to day life?

Is anything missing that you wish you could do more often?

What's the one thing that bugs you the most that you wish you could change?

MEDICAL PREFERENCES

How involved do you want to be in making decisions about your healthcare?

Is there anyone you look to or lean on for guidance and help with making medical decisions.

If a treatment could prolong your life but significantly reduce your ability to engage in meaningful activities or time with loved ones, how would you feel about that?

Are there any medical situations you would consider unacceptable or would want to avoid?

How true is this statement for you: "I value a better quality of life (even if it is shorter) vs. living longer through artificial life support.

ADVANCE CARE PLANNING

Was an Advance Directive Completed

Is following up necessary?

End Time

Time

HoursMinutes

Total Minutes