If your client has a history of Dementia, please answer the following:


Agent Name:  

Client Name: 

Phone:  

Fax: 
   

   
1.  Type of Dementia ?  

2.  Date of onset symptoms ?  

3.  Date of Diagnosis ?  

4.  Is your client on any medication ? Yes   No  If yes, give details: 



5.  Functional status ?
        Minimal Cognitive Changes, Fully Functioning
        Needs Supervision Outside the Home
        Assistance Needed on Any ADL (Activities of Daily Living)
        Custodial Care


6.  Is there also a history of depression ? Yes   No   If yes, give details: 


7.  Has your client smoked cigarettes in the last 12 months? Yes   No 


8.  Does your client have any major health problems ? Yes   No (example: heart disease, etc.)
 If yes, give details: