(256) 777-4224
Info@LiveYourLegacyHere.com
Mon - Fri | 8:30 AM - 4:30 PM
Facebook-f
Instagram
Twitter
Programs
Generations Adult Day Program
The Legacy Clinic
About Us
Our Team
Call of Nominations
Make a Difference
Volunteer
Donate
Contact
Hamburger Toggle Menu
Donate
Dementia Adult Day Program
Pre-Enrollment Questionnaire
General Information
Name Full Name of Participant
Date of Birth
Gender
Male
Female
Select Gender
Address
Primary Contact
Primary Contact Name
Primary Contact Relationship
Primary Contact Phone Number
Primary Contact Email
Emergency Contact
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number
Diagnosis & Medical History
Has the participant been diagnosed with dementia?
Yes
No
Select
If yes, what type?
Date of Diagnosis (if known)
Other Diagnosed Medical Conditions
Physician’s Name
Physician’s Contact Information
Does the participant have a history of falls?
Yes
No
Select
Does the participant have a Do Not Resuscitate (DNR) order?
Yes
No
Select
List any allergies (medications, food, environmental)
Cognitive & Behavioral Considerations
Current Stage of Dementia (if known):
Mild
Moderate
Advanced
Select Stage
Does the participant experience any of the following? (Check all that apply)
Wandering
Agitation
Anxiety
Depression
Sundowning
Hallucinations
Repetitive Behaviors
Resistance to Care
Aggression
Paranoia
If any of the above, what strategies have worked best to calm or redirect the participant?
Can the participant recognize familiar faces?
Yes
No
Sometimes
Select
Can the participant express their needs verbally?
Yes
No
Limited
Select
Daily Living & Mobility
Does the participant require assistance with any of the following? (Check all that apply)
Eating
Toileting
Dressing
Grooming
Bathing
Walking
Transferring (e.g., chair to bed)
Mobility Status
Walks independently
Uses a cane/walker
Uses a wheelchair
Select Status
Dietary Restrictions (if any)
Is the participant incontinent?
Yes
No
Occasionally
Select
Does the participant require assistance with eating?
Yes
No
Select
Social & Activity Preferences
Has the participant previously attended an adult day program?
Yes
No
Select
What are the participant’s favorite hobbies or past interests?
Preferred Activities (Check all that apply)
Music
Art
Puzzles
Gardening
Exercise
Group Discussions
Socializing
Crafts
Religious Activities
Other:
Medications & Medical Needs
Is the participant currently on any medications?
Yes
No
Select
If yes, please list medications and dosages
Does the participant need assistance taking medications?
Yes
No
Select
Does the participant have a history of seizures?
Yes
No
Select
Does the participant require oxygen?
Yes
No
Select
Caregiver Support & Goals
What are the main reasons you are considering our dementia day program?
Respite for caregiver
Socialization for participant
Structured cognitive activities
Assistance with daily living
Other (please specify):
What are your biggest concerns about the participant’s condition?
What are your expectations for the program?
Transportation & Scheduling
Does the participant need transportation to and from the program?
Yes
No
Select
Preferred Schedule
Full-Time
Part-Time
Number of Days Per Week
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Additional Notes
Is there anything else we should know to provide the best care?
Send
