Alzheimer’s Society’s enquiry categorisation.doc

Enquiry record form Enquirer’s name: (if supplied) Date of enquiry: Date actioned initials: Address:(if supplied) Postcode: Duration: Enquirer’s phone:(if supplied) Enquirer’s email:(if supplied) Brief details of enquiry information given: (continue on the back if necessary) Further action required: Top part of form to go to case notes? ( Where case notes shared, client informed ( Enquiry statistics (detach if filing top part of form in case notes) Needed for Common Activities Database Not needed for Common Activities Database Enquirer (tick only one box) Carer or relative Person with dementia Carer/relative and person with dementia Person worried self may have dementia Person worried someone else may have dementia Carer/relative and person worried s/he may have dementia Professional – social work department Professional – health service Professional – multi-agency Student Other Info type (tick all that apply) About dementia treatment About non-Alzheimer Scotland services About caring Legal financial Alzheimer Scotland related enquiries Other Mode (tick only one box) Phone call Visit to the office Home visit Letter Email Other/outside contact Actions (tick all that apply) Information materials provided Referred to social work department Referred to health service Referred to Alzheimer Scotland contact, eg Helpline Referred to Involvement Officer Referred to other voluntary organisation Referred to counselling Enquiry type (tick only one box) Info only Emotional support and info Emotional support only Involvement  Enquiry details continued Subcategories - for optional service use only; not required for Common Activities database Info type About dementia treatment Alzheimers Vascular dementia Dementia unspecified Dementia in younger person Diagnosis CJD Downs / learning disabilities Frontal lobe/Picks Lewy body Rare dementia Genetics Aricept /donepezil Exelon /rivastigmine Rem