e:/fileroot01/2017-7236950fb90-3599-4901-b278-6bc9a74e58e27692c3d133f3a7a3a4fbcd1a8c6970b7.pdf 12/06/06Enquiry record formEnquirers name: (if supplied)Date of enquiry:Date actioned & initials:Duration:Enquirers phone:(if supplied)Address:(if supplied)Postcode: Enquirers email:(if supplied)Brief details of enquiry & information given: (continue on the back if necessary)Top part of form to go to case notes? Further action required: 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 DatabaseMode (tick only one box)Phone callVisit to the officeHome visitLetterEmailOther/outside contactActions (tick all that apply)Information materials providedReferred to social work departmentReferred to health serviceReferred to Alzheimer Scotland contact, eg HelplineReferred to Involvement OfficerReferred to other voluntary organisationReferred to counsellingEnquirer (tick only one box)Carer or relativePerson with dementiaCarer/relative and person with dementiaPerson worried self may have dementiaPerson worried someone else may have dementiaCarer/relative and person worried s/he may have dementiaProfessional social work department Professional health serviceProfessional multi-agencyStudentOtherInfo type (tick all that apply)About dementia & treatmentAbout non-Alzheimer Scotland servicesAbout caringLegal & financialAlzheimer Scotland related enquiriesOtherEnquiry type (tick only one box)Info onlyEmotional support and infoEmotional support onlyInvolvementStaff or volunteer name:Enquiry details continuedSubcategories - for optional service use only; not required for Common Activities databaseInfo typeAbout dementia & treatment Alzheimers Vascular dementiaDementia unspecifiedDementia in younger personDiagnosisCJDDowns / learning disabilities Frontal lobe/Picks Lewy body Rare dementiaGeneticsAricept /donepezilExelon /rivastigmineReminyl /galantamineEbixa /memantineDrugs in developmentOther infoAbout non-AS servicesGeneral services info Health servicesSocial work servicesHousingAdvocacyLong stay careDomiciliary careDay care Respite careBefriendingContinuing care/hospital discharge Other infoCaringCaring strategiesBehavioural drugs issuesEquipment Mistreatment /abusePalliative care Complementary therapiesOther infoLegal & financialWelfare benefitsCouncil taxFinancial assessment for community care Free personal carePower of attorneyGuardianship /intervention orderAccessing fundsMental Health Act DebtOther financial matters Other legal mattersAS-AD enquiriesAbout our workPublications orderWants to donateWants to volunteerOther AS-AD info