NEED SOME HELP REMEMBERING THINGS?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Do you have a good memory?
Yes No
Do you miss appointments?
Yes No
Do you forget to turn off home appliances such as: cooker/oven/iron
Yes No
Do you sometime forget to turn off taps?
Yes No
Do you sometimes forget to close the front door?
Yes No
Do you forget the time or date?
Yes No
Have you forgotten to take your medication or taken a dose twice?
Yes No
Can you see the medication labels?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No