What You Need to Know About Me If I Get Dementia Workbook
This workbook is for the person with memory loss. This is a way for you to share what is important to you. It is also a great way to be understood by the people who are helping you to live with the diagnosis of Alzheimer’s or some other type of dementia with memory loss.
This is how I feel about having memory loss: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Symptoms to be concerned about: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
This is my address: ______________________________________________________________________________
This is my phone number: ______________________________________________________________________________
This is my Physician’s phone number: ______________________________________________________________________________and address: ______________________________________________________________________________
This is my diagnosis: _____________________________________________________________
This is my spouse/child/friend phone number: ______________________________________________________________________________
______________________________________________________________________________
Things that upset me: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I don’t like it when someone: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I do like it when someone: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I am allergic to: ____________________________________________________________________________________________________________________________________________________________
Food I like: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Snacks I Like: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Foods I don’t like: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I like to eat breakfast (at what time?) _______________________________________________
I like to eat lunch (at what time?) __________________________________________________
I like to eat dinner (at what time?) __________________________________________________
I like to cook… yes or no? _________________________________________________________
My favorite drinks are: ______________________________________________________________________________
I can or cannot operate a microwave _______________________________________________
I can or cannot operate a stove ____________________________________________________
I have trouble running the dishwasher ______________________________________________
I am having trouble understanding conversations _____________________________________
This is how that makes me feel: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My favorite TV shows and times/days they are on : ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My favorite movies: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I can or cannot operate the TV by myself ____________________________________________
Favorite Radio shows and times/days they are on: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I can or cannot operate the radio by myself: __________________________________________
Favorite music is: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I like to have music on rather than the TV ____________________________________________
Favorite sports and teams are: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Favorite gameshows: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Favorite Reality Shows are: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My favorite hobbies are: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I like crafts: ____________________________________________________________________
I like to garden: _________________________________________________________________
People who make me feel good: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
People who make me laugh: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
People who upset me: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Where I lived as a child: ____________________________________________________________________________________________________________________________________________________________
My favorite childhood memories: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My favorite relatives: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
People I like to call and chat with and their phone numbers: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What I did for a living/ jobs I had and what was my age when working there? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I like to shower on these days and times: ____________________________________________________________________________________________________________________________________________________________
I like baths on these days and times:
____________________________________________________________________________________________________________________________________________________________
I like my baths hot? Warm? Bubbles? Candles? Music? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I have a specific bathing routine __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I need quiet times _______________________________________________________________
I need entertainment ____________________________________________________________
I like to read books, magazines __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I search the internet for ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My cell phone is important to me __________________________________________________
I use it for: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I use my home computer often ____________________________________________________
I like to take pictures on my phone of: ____________________________________________________________________________________________________________________________________________________________
I like putting pictures in folders ______________________________________________________________________________
I need help downloading my pictures _______________________________________________
I need help managing my minutes on my devices _____________________________________
______________________________________________________________________________
Location of important paperwork: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Women – I like wearing makeup what/how do you apply it and where? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Men – I like to get my hair cut when? Where? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Women – I like to get my hair cut when? Where? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I like to wear jewelry like: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
My favorite clothes are : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________My favorite shoes are: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I wear hats! ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I am a neat freak ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I don’t care about tidiness ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other important things I need someone to know about me: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Resource:
Jill Lorentz
Summit Resilience Training Inc. Dementia Education for Caregivers
www.summitresiliencetraining.com
jill@summitresiliencetraining.com
