Needs Survey

My loved one…

1) is forgetful – often repeating themselves or asking the same questions.

YES      NO

2) forgets the names of common items, places, or people they’ve known many years.

YES      NO

3) needs assistance to manage their financial affairs, checkbook, household…

YES      NO

4) does not participate in activities as often as they used to (church services or functions, family gatherings, social events, clubs…)

YES      NO

My loved one…

5) has shown suspiciousness and/or paranoia by making statements that someone else took or moved the missing – (keys, watch, purse, checkbook…) or other similar remarks.

YES      NO

6) is easily upset when corrected and/or may become verbally aggressive.

YES      NO

7) resists personal hygiene and/or often wears the same clothing over and over.

YES      NO

8) needs assistance with every day tasks like dressing, brushing teeth, shaving…

YES      NO

9) does not sleep through the night and may wander the house

YES      NO

10) personality is different now from the way they were all their life.

YES      NO

The Pathways to Memory™ program is a social / behavioral model of memory intervention whose ultimate goal is to assist our clients maintain or regain their cognitive abilities, increase their self esteem and maintain or regain functions of independence.