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:Alonewith spousewith childrenwith other relative/non-family member

Marital Status:Single Married Devoiced Widow Wheelchair assisted?: YesNo

Source of finance: CSSAOther governmental aidSupported 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 ChildrenOther (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 AgencyActivities of HKADA PublicityMedia

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