Developmental Disabilities and Alzheimer’s Disease Prevalence and Needs Questionnaire

Are you a:
Family Member/Guardian
Paid Caregiver
Organization
Date of birth of individual in care:
(mm/dd/yyyy) / /
Zip Code
Gender of individual in care:
Male
Female
Race of individual in care:
White
African American/Black
Asian
American Indian/Alaskan Native
Pacific Islander Other
Ethnicity of individual in care:
Hispanic/Latino
Non-Hispanic
Has the individual been diagnosed with dementia/ Alzheimer’s disease?
Yes
No
Has the individual been diagnosed with Down syndrome?
Yes
No
Has the individual been diagnosed with other developmental disabilities?
Yes
No
If yes, which ones:
Cerebral Palsy
Autism
Mental Retardation
Learning Disability
Epilepsy
Other

If you have answered “No” to either question #7, or question #8 please stop here and click the 'Submit' button. Otherwise, please complete the rest of the survey and click the 'Submit' button at the end of the form.
Is the individual living in:
Residential/Nursing Home
Assisted Living
With Family
Independent Living
Is there an increased risk of Alzheimer’s in people with Down Syndrome?
Yes
No
Don't Know
Has a complete neurological exam including mental status exam been conducted?
Yes
No
If yes, how long ago was the last exam conducted?
1-6 months
7-12 months
13 & above
Has a complete psychiatric evaluation been conducted?
Yes
No
If yes, how long ago was the last exam conducted?
1-6 months
7-12 months
13 & above
Please rate the general medical service(s) received for the individual on a scale of 1-5
(1 being worst and 5 being the best)
1. Physicians have adequate training to provide services
  1 2 3 4 5
2. Medical staff has adequate training to provide services
  1 2 3 4 5
What type of training would you like to see the Physicians/ Medical staff have?
Do you feel that the Primary Caregiver has adequate training to provide assistance to the individual?
Yes
No
Please rate the training of the Caregiver on a scale of 1-5
(1 being worst and 5 being the best)
1. Caregiver has adequate training to provide services
  1 2 3 4 5
What type of training would you like to see the Caregiver have?
What other non-medical services are currently being provided to the individual and by whom?
What are some others needs or services that you feel are important but are not being met?

If you know someone in this population, and would prefer to complete the questionnaire offline, please assist the Bridging the Gap Task Force by downloading the questionnaire and returning it to:

Kris Baldwin or Susie Keesling
P.O. Box 1437 Slot S530
Little Rock, AR 72203

For more information contact:

Kris Baldwin at 501-682-8509 or
Susie Keesling at 501-682-2418
Fax: 501-682-8155