MIME-Version: 1.0 Content-Location: file:///C:/C3551CF4/ALZHEIMERS_PATIENT_FACT_SHEET.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" ALZHEIMERS PATIENT FACT SHEET

ALZHEIMER’S POLICE COLLECTIO= N FORM

Newbury Police Department

25 High Road

Newbury, MA 01951<= /o:p>

(978) 462-4440

ELDER/ PATIENT INFORMATION

            Date:  = ;            &n= bsp;

 

NAME:  &nb= sp;                   &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                    &= nbsp;           &= nbsp;           &nbs= p;  

 

ADDRESS:         =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =               &= nbsp;           &= nbsp;  

 

DOB:         &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;             &= nbsp;           &nbs= p;   SS#:        &= nbsp;           &nbs= p;            &= nbsp;               &= nbsp;           &= nbsp;  

 

PHONE #: (        =     )

 

Gender:  = ;           Race:<= u>        &= nbsp;               &= nbsp;   Language:         =              Height:        &= nbsp;            &= nbsp;  

 

Weight:        &= nbsp;            &= nbsp;   Eyes:        &= nbsp;               &= nbsp;   Hair:        &= nbsp;                &= nbsp;   Build:        &= nbsp;              &= nbsp;  

 

Handed:  R  L   AMB      Glasses:  YES   NO       Facial Hair:   YES  NO

 

Cane:  YES  NO            WIG/TUPE:  YES  NO    Hearing Aid:  YES  NO

 

Please list any distinctive marks, moles, scars, tattoos or jewelry worn:

 

 

 

Please check which of the following signs & symptoms are currently being displayed.  As the disease progresses & sy= mptoms increase, please notify us of such changes.  Check ALL that apply.  Y= ou can elaborate in the space below.

 

`= 33; Restlessness     &= nbsp;       □ Anxiety      =     □ Agitation     &nbs= p;  □ Hallucinations     &nbs= p;       □ Delusions      

`= 33; Suspiciousness     &nbs= p;    □ Paranoia      = ;  □ Seizures      = ;  □ Harms him/herself (if so describe)

`= 33; Unable to speak; grunts & groans as a means of communication=

`= 33; Gets confused about the location of familiar places

`= 33; Has difficulty recognizing family & friends

`= 33; Wanders away regardless of dur= ation or distance wandered (if so, please describe)

`= 33; Physically= violent toward family, friends &/or caregivers (if so describe)

 

 

 

 

 

Are there any other h= ealth/ medical concerns?  YES  NO      Is the eld= er on any medications?   YES NO=

            If Yes to either question, please describe.

 

 

 

 

 

Currently attends Out= -of-Home Programs:   YES    NO

            If Yes, where and what are the hours?

 

 

 

 

Is Merrimack Valley E= lder Services or the Council on Aging involved at this time?   YES   NO

            If yes, caseworker’s name?

Primary Healthcare Pr= ovider, Practice & Telephone #:

 

 

Is the elder currently enrolled in the Alzheimer’s Association “Safe Return” Program?  = YES  NO

 &= nbsp;      If no, refer caregiver to=   (800) 548-2111 or www.= alz.org for support and “Safe Return” info.

 

Does the elder have a= ccess to a motor vehicle, if so, what is the registration number & state?

 

 

Does the elder have a= License to Carry a Firearm?    YES   NO

Are there firearms in the home?   YES   NO

  &n= bsp;            = ;         If so, what kind:

 

 

 

 

PRIMARY EMERGENCY CONTACT INFORMATION=

 

Are you the person completing this questionnaire= ?    YES   NO 

 

RELATIONSHIP TO ELDER:            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =    

 

NAME: &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;        <= /p>

 

ADDRESS: &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             

 

DOB:  &n= bsp;            = ;            &n= bsp;            = ;            =         &= nbsp;           &nbs= p;   SS#:        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      

 

HOME PHONE #: (        =     )

 

WORK PHONE #:&n= bsp; (        =    )      = ;            &n= bsp;            CELL PHONE #:  (        =   )

 

 

SECONDARY EMERGENCY CONTACT INFORMATION

 

 

RELATIONSHIP TO ELDER:            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =    

 

NAME: &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;        <= /p>

 

ADDRESS: &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             

 

DOB:  &n= bsp;            = ;            &n= bsp;            = ;            =         &= nbsp;           &nbs= p;   SS#:        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;      

 

HOME PHONE #: (        =     )

 

WORK PHONE #: (        =     )      = ;            &n= bsp;            CELL PHONE #:  (        =   )

 

Please list any other emergency co= ntact on the back of this sheet.

 

Is there anything oth= er information that you think would be helpful for the police department to kn= ow in order to provide a safe & rapid response?

 

 

 

 

 

 

 

            =             &nb= sp;            =             &nb= sp;            &nbs= p;            &= nbsp;           &nbs= p;                &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;

Yo= ur Signature &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;  Police Officer Signature=

BE SU= RE TO ATTACH A RECENT PHOTOGRAPH OF THE ELDER