Dementia

10 December 2008

Information for people filling-in

Here is a form which you could print out and give to whoever is filling-in for you.

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Completing this section will give whoever’s filling-in for you an insight into your loved one’s life, helping them understand the significance of stories and names and provide a basis for casual conversation.

Birthdate:


Birthplace:


Favourite name(s):


Spouse’s name and birthday:


Terms of endearment:



Wedding anniversary:


Years together:


Children: Name(s) and birthdays:





Grandchildren: Name(s) and birthdays:





Close friends: Name(s) and birthdays:





Place(s) lived:





Job(s)/Occupation:





Other useful information:








For more information visit: Dementia SA: http://www.dementiasa.org/ or Alzheimer’s South Africa: http://www.alzheimers.org.za/

 

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