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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