| General information | Yes | No | N/A |
| 1. Has relevant personal information been gathered?NameDate of birthLegal state of residenceHealth status, including medications being takenMarital statusFamily members available for supportName, phone number, and address of attorney, physician, geriatric care manager or other advisor | | | |
| 2. Has financial situation been assessed?Income from Social Security, pension, employment, or other sourceExpensesAssetsLiabilities | | | |
| Notes: |
| Long-term care planning | Yes | No | N/A |
| 1. Is the need for long-term care imminent? | | | |
| 2. Are assets sufficient to cover long-term care needs? | | | |
| 3. Have ways to fund long-term care been reviewed/evaluated? | | | |
| 4. If homeowner, has home equity as a use of funds been discussed? | | | |
| 5. Are long-term care insurance benefits available? | | | |
| 6. Have various housing options and their costs been considered?In-home careLiving with a relativeContinuing care retirement communityAssisted livingNursing home | | | |
| Notes: |
| Insurance planning | Yes | No | N/A |
| 1. Is adequate health insurance available?MedicareMedigapPrivate health insurancePrescription plans | | | |
| 2. Have Medicaid planning goals and strategies been considered? | | | |
| 3. Has Medicaid qualification criteria been discussed? | | | |
| 4. Has the need for long-term care insurance been established? | | | |
| 5. Is long-term care insurance coverage available to the client? | | | |
| 6. Have existing long-term care insurance policies been reviewed/evaluated? | | | |
| 7. Does long-term care insurance coverage need to be upgraded? | | | |
| 8. Do long-term care benefits need to be accessed? | | | |
| Notes: |
| Estate planning | Yes | No | N/A |
| 1. Has long-term care planning been coordinated with estate planning needs? | | | |
| 2. Have appropriate estate planning documents been prepared?WillTrust | | | |
| 3. Have advanced medical directives been prepared?Durable power of attorneyLiving willHealth-care proxy | | | |
| 4. Have letters of instruction been prepared? | | | |
| 5. Has this information been communicated to family members? | | | |
| Notes: |
| Other | Yes | No | N/A |
| 1. Has the need for organizing important documents and records been discussed?Bank account records (statements and passbooks)Monthly bills to be paidStock certificates, bonds, and other investment recordsRetirement plan statementsReal estate deeds, mortgages, and other property ownership recordsVehicle titlesBusiness agreementsInsurance policiesWill, trust, advanced medical directives, letters of instruction, and other documentsBirth certificate, marriage certificate, divorce decree, military service papers | | | |
| Notes: |
