Below is a Senior Profile template.

The Template contains important, personal information.

First, please copy the profile form and prepare the answers. When finished, please submit to Template@seniorcallup.com



An important issue of concern for seniors is their medication and whether they adhere to the prescriptions given to them by their doctors.

Resent studies have found that only about half of people with chronic conditions like heart disease, diabetes, and high blood-pressure take their medicines as prescribed. More so for seniors with failing memories. We recommend that our Personal contacts inquire with the Senior whether he/she has taken the medicines.



The “Primary contact” is usually the person who subscribes to the SeniorCallup service. However, another person may be designated as the “Primary Contact.” The Primary Contact will be called in case of emergency. Also, the Primary Person will receive our weekly email summary reports.

Name: _______________________________________________________

Relationship to the Senior to be called: ____________________ 

Address: ____________________________________________________

Telephone: __________________Mobile telephone, if any: ______

E-mail: _____________________________________________________

Other: ______________________________________________________

Secondary contact:

            Name: ___________________________________________

            Telephone:_________________ Mobile: _____________

            Relationship to the Senior: _____________________

Senior to be called.

(If more than one Senior, please prepare a questionnaire for each person.)

Name: ____________________ Nickname, if any:_________________

Age: _________M/F: _______ Married/widowed/single: __________

Town and State: _____________________________________________

Living quarters: 

House: ____ Apartment: ______ Home: ______Other: ____________

Telephone: ________________ Mobile telephone, if any: _______

Primary Physician: _______________________Telephone: ________

Other: ______________________________________________________

MEDICINES:

Pharmacy: ___________________________________________________

Address:  ___________________________________________________

Telephone: __________________ Contact: ______________________ 

HEALTH ISSUES:

Any disabilities? ____________________________________________________________

Hearing impairment? __________________________________________________________

Cognitive or emotional issues?________________________________________________

Forgetfulness? _______________________________________________________________

Any other health related issues we should know about or check up on?
______________________________________________________________________________

______________________________________________________________________________


BACKGROUND INFORMATION:

Children: (Only first names, sex and age.): __________________________________

Grandchildren? _______________________________________________________________

First names, sex and ages. ___________________________________________________

Pets: _________________ If so: name: _________________________________________

Church/other:_______________ Attends? ________________________________________

Social groups he/she participates in:_____________ Frequency: ________________

Educational level: ___________________________________________________________

What occupation did the person have? _________________________________________

What hobbies does the person have? ___________________________________________

Does the senior have any special interests? __________________________________

What does the person like to talk about? _____________________________________

What special concerns does the person have? __________________________________

EMERGENCY CONTACTS:

In case of an emergency, we will FIRST call Emergency services as required.

Also, we will call the Primary Contact. 
If the Primary Contact cannot be reached, we will call the Secondary Contact 
to inform about the situation and receive guidance as to what action to take.


While contacting the Primary contact, or others, via a different telephone, 
we will stay on the direct telephone with the Senior until help arrives.

EMERGENCY CONTACTS:

Police: ___________________________________ Telephone: _______________________

Fire station: _____________________________ Telephone: _______________________

Emergency Medical: ________________________ Telephone: _______________________

Others: ___________________________________ Telephone: _______________________


Neighbor or local friend.


Name: _________________________________________________________

Telephone: ____________________________________________________   

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