Fix Dementia Care emergency admissions survey

Fix Dementia Care emergency admissions survey

1. Which of the following statements best describe your connection with dementia? Please select all that apply.

I have dementia, dementia symptoms or a mild cognitive impairment
I am a carer of someone with dementia
I used to be a carer of someone with dementia
I am a family member or friend of someone with dementia
I was a family member or friend of someone who had dementia
I work with people affected by dementia
I am generally interested in dementia
Other (please specify):

2. Have you, or someone you know who has dementia, been rushed to hospital in an emergency that could have been prevented with better community care? This could include: *

Comments:

3. Is the hospital experience you are referring to happening now, or was it in the past? *

Now
In the past

4. Where in the country did this happen?

5. Please tell us more about your experience - for example, what was the emergency, how did it happen? How long was the hospital stay, and what happened after leaving the hospital? What impact did this all have on the health and wellbeing of the person with dementia? *

6. Your survey responses are completely private, but in future we’d like to share people’s stories as part of our campaign to fix dementia care. This could involve local or national newspapers, radio or television. How could you help us with this? Please select all that apply:

Share a write-up of your story
Share pictures to go with your story
Talk to a journalist on the phone
Talk to a journalist in person
Talk to a journalist on camera
I don’t want to share my story

7. If you are interested in sharing your experiences with Alzheimer’s Society to help us campaign for change, please leave your contact details below.

These will only be used for Alzheimer's Society to contact you about our campaign, and will not be used for other purposes or shared with anyone else without your permission.

First name
Last name
Email address
Phone number
Postcode