Dementia Active - Initial Sign up

Questions to family members/carers.

Before completing this form it is important to consider whether the person on whose behalf you are requesting a place, will be able to function safely in a group. Whilst we would wish to accommodate everyone who makes a request, it is sadly the case that some of the behaviours exhibited by people with dementia are not possible to manage in a group setting. So for instance - anxiety which may show itself in the form of uncontrolled shouting out, banging tables, throwing things or threatening behaviour will be too upsetting and disturbing for established group members to deal with.

Please fill in this form before arranging a home visit with 'Dementia Active'

Person wanting to attend the group

Name

First NameLast Name

Date of Birth

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email (This can be a partner, relative or close friend. Email sent from us may contain sensitive information)*

example@example.com

Phone Number (This can be a partner, relative or close friend. Phone conversations from us may involve the discussion of sensitive or personal issues)

Area CodePhone Number

Family member/friend completing this form

(if applicable)

Name

First NameLast Name

Your relationship to the person who would like to attend a group.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Groups

Has your relative/friend ever attended social groups unaccompanied by family members and if so, approximately how long ago?

Are they likely to enjoy social/activity groups?

What might they not like about being in a group?

Refreshments/Dietary needs

How does your relative/friend take their tea/coffee?

Do they have any food allergies?*

Do they have any food intolerances?*

Do they have any specific dietary requirements?

Interests/hobbies

What were their former main interests or hobbies?

What three things do they take pleasure in doing now?

Do they have any talents they might enjoy sharing with the group for instance playing a musical instrument/singing?

What are their three favourite songs?

Although the aim of Dementia Active is for members to find new interests....do they have any current hobbies or interests which Dementia Active can support them with? Carrying out a familiar activity can help a person feel at home in the group more quickly.

Emotions/behaviour

Does your relative/friend enjoy lots of attention or do they prefer to quietly observe?

What might they do if they become upset or angry?*

Do they enjoy gentle teasing and laughter with people they know?

When anxious do they do show any behaviours which might upset other members of the group? *

Have they ever left the family home without telling anyone and become lost?*

Family History

Are there any specific memories which might cause distress, for instance the recent loss of a loved one, or having to leave their own home?*

What was their career?

Where were they born and what are the key places they have lived in?

Are there any significant events in their lives which they still enjoy remembering and talking about?

Are there any specific memories from their childhood which might cause distress when doing Reminiscence exercises.*

Medical

Does your family member/friend have hearing loss/wear a hearing aid?

Does background music disturb their concentration?

Do they have impaired vision and normally wear glasses for long distances?

Do they need to wear reading glasses?

Do they hear or see better on one side than the other?

Do they have visual/spatial difficulties e.g. not being able to judge the depth of steps?*

Do they experience visual disturbance e.g. seeing objects which aren’t there, imagining that a dark mat is a hole in the ground?*

Do they use a walking aid in the house/outdoors or need someone by their side when walking?*

In the past 12 months have they fallen and if so how many times has this occurred? *

Do they have any medical conditions which might prevent them taking part in gentle exercise programmes; walking short distances; catching and throwing balls - for instance painful shoulders, breathing difficulties or a heart condition?*

Do they need to carry an inhaler?*

Have they ever showed signs of experiencing hallucinations?*

Do they have any difficulties with continence?*

Are they able to use toilet facilities without assistance?*

Do they normally take lunchtime medication and if so how will the daily schedule of tablets be managed on the day they attend Dementia Active?*

If there needs to be a change in timings of medication administration what impact might this have, for instance might they become very tired by the end of the session?

Which of the following applies to your family member or friend: They have a diagnosis of dementia.They have concerns about memory problems but have not received a diagnosis.They would like to attend groups for social reasons.*

If your family member has been given a dementia diagnosis, what form does this take? If you have not been told, please say this.

Joining a new group

Are you willing to accompany your relative/friend to the first few sessions to help them settle into the group?

If the person is finding it difficult to settle into the group are you happy for them to attend for a shorter length of time to help them adjust to being in a group?

Do you have any concerns regarding the wellbeing of your relative/friend in a group setting?*

Cultural/spiritual needs

Does your relative/friend hold any religious or cultural beliefs which Dementia Active need to be aware of?*

Finally

It is important that Dementia Active is informed of any health problems as they arise. Likewise - any changes in medication which might impact on a person’s mood or ability to function in the group.

Official Use Only

Home Visit/ initial contact notes