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Individuals with Dementia from Diverse Cultural Backgrounds: a Person-Centered Questionnaire

Please complete all the fields in the questionnaire. If you do not know a specific answer, leave it blank or mark "I don't know." The more detailed and complete your responses, the more accurate and helpful the recommendations will be in improving daily interactions and care. This questionnaire has been designed to collect detailed information about the older individual, allowing for a more personalized approach to their care. The responses provided will help generate a report with tailored suggestions and strategies based on their life history, culture, and current condition. Since many older adults are immigrants, this questionnaire aims to capture their cultural background, traditions, and past experiences, offering insights to facilitate communication and caregiving approaches that align with their personal history.

Social/Cultural background

Name and Last Name (Just Initials):

Place of birth (country and city):

Gender:

Date of Birth:

Languages spoken:

Do they have a religion or meaningful beliefs? If so, specify

Do you know if they have any special cultural tradition? If so, specify

Marital Status (married, widowed, single, divorced, partnered)

Have they immigrated? If yes, when and where did they move to and why?

Do they have children? If so, mention quantity and for grandchildren as well

Are family members present in the person's daily life?

Food Preferences (mention here favourite dishes and major dislikes)

Current Residential style (where they live)

Which of the following resources are available for the individual's daily activities?

Music room Art/Craft room Adapted kitchen Meditation/Prayer room

If you tick other, please specify

Occupation and Interests

What is their level of education (How many years of study and their certificates):

Are they able to read or write in any language?

Occupations throughout their life:

Do they have HOBBIES (indicate if it is past or currently):

What they like watch on TV and listen on radio?

What they like to do during free time (past and current interest):

Preferences and Daily Routine

Daily Routine:

What time of the day is the person the calmest and most receptive:

How do they prefer to be approached? (Example: being called by their first name, direct eye contact, soft tone of voice):

Are there any familiar words or phrases in their native language that could help with communication?

What personal objects or activities bring them comfort?

Do they usually sleep well? (Yes / No, they have insomnia or wake up frequently)

How do they react to physical touch? (Enjoys it / Prefers personal space / Depends on the person)

Medical History

Please provide summary of their medical history, including diagnosis:

Medications:

Cognition and Behavior (Any Physical or Cognitive Decline):

Mobility:

Sensory:

Nutrition and Hydration:

Personal Care:

Toileting and Continence:

If you are unsure of your answers, you may select from the options below instead of typing. Otherwise just skip to the "Carer Details" section.

Carer Details

This section is about the person filling this form. We need to know your relationship with the older adult, your country of residence, and the language you speak to better assist you.

Level of Relationship with the person you are seeking guidance for

YOUR Place of birth (country and city)

YOUR Place of Residence

Were you born in the same cultural background as the individual you are seeking guidance for?

In which language would you like to generate this report? (If English is not your native language feel to request any other language)

What are your expectations for this report?

Individuals with Dementia from Diverse Cultural Backgrounds: a Person-Centered Questionnaire

Social/Cultural background

Occupation and Interests

Preferences and Daily Routine

Medical History

Sensory background

Hearing

Visual

Taste

Expression language

Sensory background

Nutritional data - Level of food

Nutritional data - Level of drink

Mobility Data

Cognitive Abilities and Behaviors

Carer Details