Hong Kong Alzheimer’s Disease Association
Service Application Form
Date:______(DD/MM/YY)
Service Centre : Brain Health Centre (Kowloon) Jean Wei Centre (Hong KongIsland)
Tung Sin Brain Health Centre (Hong KongIsland)(Please)
Part I:Patient’s Background Information
Patientname:______(in BLOCK LETTER) Sex: Male/Female Age:______
Date of Birth:______(DD/MM/YY) ID Number:______
Occupation before retired:______Language: ______Place of Origin:______
Educational level: PrimarySch. Secondary Sch. University or above
Residential Address:______Tel No.:______
Living Condition:Alonewith spousewith childrenwith other relative/non-family member
Marital Status:Single Married Devoiced Widow Wheelchair assisted?: YesNo
Source of finance: CSSAOther governmental aidSupported by Children Saving Other:____
Cared by maid:Yes No Receiving other Social Service: Yes(please specify)______No
Diagnosed dementia by physician: Yes No Under medical treatment now: Yes No
Any other chronic illness: Yes No (if yes, please specify) ______
Part II: Applicant and/or Carer Information
Name of Applicant: ______Tel no.:______
Relation with patient: Spouse Children Other (Please specify):______
Mailing Address: ______Mobile No.:______
E-mail address(if any): ______Fax Number: ______
Name of Main Carer(if different from applicant): ______Sex: M/F Age:______
Relation with patient: Spouse ChildrenOther (Please specify):______
Live with the patient: Yes / No Stress level of Caring (1-10, 1=No stress; 10=very stress):______
Feel interest to attend in training course? Yes / No Feel interest to visit by volunteer: Yes/No
Ways to know us? Friend Social Service AgencyActivities of HKADA PublicityMedia
Declarationof Personal Data Collection
I(the applicant) agreed and understood that the personal data I have provided is used forprocessing the service application of HKADA.
Signature of Applicant: ______
Date:______
Please send the completed form together with the certification letter by physicianto the Service Manager of Hong Kong Alzheimer’s Disease Association(HKADA) by facsimileor by mail.
Address: / Fax: / Tel:Brain Health Centre: G/F, Wang Yip House, Wang Tau Hom Estate, Kowloon / 2338 0772 / 2338 1120
Jean Wei Centre: 1/F, TangShiuKinHospital, 282 Queen’s Road East, Wanchai, Hong Kong / 3553 3653 / 35533650
Tung Sin Brain Health Centre: 7A,Winbase Centre, 208-220 Queen's Road Central, Sheung Wan,HK / 2815 8408 / 2815 8400
Revised on 2.2012 HKADA-Form-Service-001