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Your name |
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Address |
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Phone Number |
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Name of loved one |
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Does your loved one have difficulty with memory loss (forgetting people, events, instructions) |
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Does the person have a sense of time (knowing day, year, place) |
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Do you have advanced Directives in place? |
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Describe the person’s personality prior to onset (outgoing, quiet, talkative, etc)? |
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Have you seen a change in personality? |
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Do they have any children? |
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If so, how many? |
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Name(s): |
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What type of work or hobbies did the person enjoy before the onset of memory loss? |
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What type of things do they do now to keep busy or for enjoyment? |
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Describe any difficulties that you are having with your loved one (refuses to bathe, repetitive questions, anger, lack of activities that bring enjoyment, etc)? |
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Please DESCRIBE the following activities using the included questions to help you describe them. |
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Dressing |
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Does the person dress themselves? Do they need to be reminded to dress? Do they pick their own clothing? Do they ignore weather conditions or social customs, button alignment or daytime vs. night garments? Are colors or patterns of garments coordinated? |
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Bathing |
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Does the person bathe without assistance using soap and shampoo, washing all parts? Does the person only bathe the front of the body and forget the back or may not get all shampoo out of hair. Does the person need reminders to bathe? |
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Housekeeping |
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Does the person participate in any housekeeping tasks? Is the person able to plan a schedule for completing chores, anticipate hazards and plan for long-term maintenance? |
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Food Preparation |
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Is the person able to plan a menu for a meal? Can they follow a recipe? Do they consistently turn off the stove and avoid burning food? Do they have only a few items in their diet and do not prepare anything else? |
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Spending Money |
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Does the person pay bills, balance the check book? Do they understand the value of money? Have they forgotten to pay bills or ran out of money? |
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Laundry |
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Does the person do laundry? Are they able to sort clothing and follow washing instructions? |
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Driving |
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Does the person currently drive? If so do they only follow familiar routes? Do they ever get lost in unfamiliar territory? |
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