Wanderers Information Sheet

 

Purpose: Please use this form to provide information in case the person wanders away or becomes lost.Keep a copy of this sheet handy to give to law enforcement. All searches begin with an investigative component.  During this time you will be asked dozens of questions to aid law enforcement and search teams determine where and how to look.  This information is critical to the success of the search.  Completion of this form, before an incident, allows the searching to start sooner and aids in collecting more accurate information.

Wanderer Information

 
 

 

 


First Name:

Middle Name:

Last Name:

 

First or Nickname:

Name to call:

Social Security #

 

Home Street Address:

City:

State:

Zip Code:

 

Local Street Address: (if applicable)

 

City:

State:

Zip code:

Home Phone #:

 

Local Phone #: (if applicable)

 

Contact Information (person providing information)

 
 

 

 


First Name:

Middle Name:

Last Name:

 

Relationship to Wanderer:

Date Completed:

 

Home Street Address:

City:

State:

Zip Code:

 

Local Street Address: (if applicable)

 

City:

State:

Zip code:

Home Phone #:

 

Local Phone #: (if applicable)

Cell Phone #: (if applicable)

 

Pager #:

Work Phone #: (if applicable)

 

Physical Description

 
 

 

 


Date of Birth:

 

Age:

Sex:

Race:

Height:

 

Weight:

Build:

Hair Color:

Hair Length:

 

Hair Style:

Balding?

Mustache?

Beard?

 

Sideburns?

Facial Features/shape:

Complexion:

Marks/Scars/Tattoos:

 

General Appearance:

Eye Color:

 

 

Accessories and Equipment

 
 

 


Item

Owns?

Description

Missing?*

Glasses

Yes No

 

Yes

Dentures

Yes No

 

Yes

Hearing Aid

Yes No

 

Yes

Cane or walker

Yes No

 

Yes

Watch

Yes No

 

Yes

Jewelry

Yes No

 

Yes

Wallet/purse

Contents

Yes No

 

Yes

Keys

Yes No

 

Yes

Safe Return Products

 

Yes No

 

Yes

Other items (tissue, tobacco, matches, lighter, items stuffed in pockets, etc)

Yes No

 

Yes

* Complete the shaded missing column only if a wandering incident occurs.If it appears the wanderer has the item with them check yes.

 

 

Clothing Worn When Last Seen

 
 

 

 

 


Fill in this section only if a wandering incident occurs.On a separate sheet of paper you might consider keeping an inventory of the personís clothing and footwear.

 

Item

Style/Description

Color

Hat/Cap

 

 

Shirt

 

 

Pants

 

 

Dress

 

 

Sweater

 

 

Coat/Jacket

 

 

Raingear

 

 

Footwear

 

 

Hose/Socks

 

 

Underwear

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

Physical Health
 
 

 


Known Physical disabilities:

 

Uncorrected Vision:

 

Uncorrected hearing:

Known Medical conditions:

 

General Physical condition:

 

Prescribed Medications:

 

Over-the-Counter Medications:

 

Consequences of not taking medication:

 

General Physician:

Address:

 

Office Phone Number:

Emergency Phone Number:

 

Dementia/Alzheimerís Questions

 

 

 

 

Dementia Diagnosis: (Alzheimerís, Vascular, Parkinsonís, etc)

 

Neurologist/Gerontologist:

Address:

 

Office Phone Number:

Emergency Number:

MMSE Score (obtain from Physician)

 

Date of Last MMSE test

Pick the box below that best describes the subject

Mild confusion and forgetfulness, short-term memory affected.

Difficulty distinguishing time, place, and person.Some language difficulties.

Nearly complete loss of judgment, reasoning, and loss of some physical control.

 

Complete the following questions on the basis of the last two weeks.Check yes if the activity is performed even once.

Questions for Dementia Disability Assessment

Yes

No

N/A

Undertake to wash himself/herself or to take a bath or shower.

Undertake to brush his/her teeth or care for his/her dentures.

Decide to care for his/her hair (wash and comb)

Prepare the water, towels, and soap for washing, taking bath, or shower

Wash and dry completely all parts of his/her body safely

Brush his/her teeth or care for is/her dentures appropriately

Undertake to dress himself/herself

Choose appropriate clothing (with regard to the occasion, neatness, the weather, and color combination

Dress himself/herself in the appropriate order (undergarments, pat/dress, shoes)

Dress himself/herself completely

 

Questions

YES

NO

N/A

Decide to use the toilet at appropriate times

Use the toilet without ďaccidentsĒ

Decide that he/she needs to eat.

Choose appropriate utensils and seasonings when eating

Eat his/her meal in the appropriate sequence

Eat his/her meals at a normal pace and with appropriate manners

Undertake to prepare a light meal or snack for himself/herself

Adequately plan a light meal or snack (ingredients, cookware)

Prepare or cook a light meal or snack safely.

Attempt to telephone someone at a suitable time

Find and dial a telephone number correctly

Carry out an appropriate telephone conversation

Write and convey a telephone message adequately

Undertake to go out (walk, visit, shop) at an appropriate time

Decide to use a mode of transportation (car, bus, taxi)

Adequately organize an outing with respect to transportation, keys, destination, weather, necessary money, shopping list

Go out and reach a familiar destination without getting lost

Go out and reach a non-familiar destination without getting lost

Safely take the adequate mode of transportation (car, bus, taxi)

Return from the store with the appropriate items

Show an interest in his/her personal affairs such as his/her finances and written correspondence

Organize his/her finance to pay his/her bills (checks, bankbook, bills)

Adequately organize his/her correspondence with respect to stationery, address, stamps

Handle adequately his/her money (make change)

Complete his/her financial transactions adequately

Answer his/her correspondence adequately

Decide to take his/her medications at the correct time

Take his/her medications as prescribed (according to the right dosage)

Shows an interest in leisure activity(ies)

Takes an interest in household chores he/she used to perform in past

Plan and organize adequately household chores that he/she used to perform

Complete household chores adequately as he/she used to perform in the past

Stay safely at home by himself/herself

TOTALS

 

 

 

 

 

Yes

No

Does the subject know name?

Does the subject know where they are when at home?

Does the subject recognize the local neighborhood?

Does the subject recognize familiar faces?

Will subject answer to his/her name being called?

Is subject able to conduct a conversation?

Does the subject have the ability to tell time?

 

 

Yes

No

If yes please describe

Does the subject suffer from personality or emotional changes

 

Does the subject suffer from Delusions

 

Does the subject suffer from paranoia

 

Does the subject suffer from hallucinations

 

Does the subject suffer from depression

 

Has the subject experienced an emotional breakdown

 

Has the subject shown violence towards others

 

Is the subject registered in the Alzheimerís Associationsí Safe Return program

If yes, please list ID #

 

 

 

Subjectís Experience

 
 

 

 

 


Residence type

Address

City

State

Dwelling type

Years

Current

 

 

 

 

 

Previous

 

 

 

 

 

Previous

 

 

 

 

 

Previous

 

 

 

 

 

Previous

 

 

 

 

 

Childhood

 

 

 

 

 

Childhood

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

If yes please describe

Is subject familiar with area where last seen?

 

What is the subjectís favorite area?

 

Has the subject been involved with outdoor classes, scouting, military, overnight experiences, or outdoor recreation?

 

Is the subject afraid of noises, crowds, dogs, traffic, water, horses, the dark, or other items?

 

Will the subject talk to strangers?

 

Is the subject dangerous to themselves or others?

 

 

Please describe each incident where the subject wandered away.Please continue on additional pieces of paper if required.If possible, mark the location where the person was found on a map.

 

 

Incident #1

Incident #2

Incident #3

Date

 

 

 

Where the person was last seen

 

 

 

 

What was the person doing when last seen

 

 

 

 

Events that might have caused the person to have wandered

 

 

 

What actions did you take

 

 

 

 

 

Where was the person found

 

 

 

 

How was the person found

 

 

 

 

 

List any medical problems that resulted from being lost

 

 

 

What was the distance from the point the person was last seen

 

 

 

Occupation and Hobbies

 

 

Please list job occupations/major volunteer work beginning with the current or most recent.

 

Job Occupation/Volunteer Work

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list hobbies and interests.

 

Hobby or interest

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Walking Habits

 
 

 

 


Distance typically walked each day (during the past week.)

††††††††††††††††††††††††††††††††††† miles

Greatest distance walked during the past three months.

miles

Greatest distance walked during the past ten years.

miles

Number of walks during the past week

 

Estimate the greatest distance you believe the person could walk

miles

Please rate the personís ability to walk

Confined to bed, unable to walk

Requires walker or cane to walk small distances

Walks unassisted for short distances but shuffles or limps

Walks with assistance

Walks effortlessly

Please list any physical limitations to walking

 

 

 

 

Critical Wandering Patterns

 
 

 

 


Please answer the following questions in regards to the last 6 months

 

Yes

No

If Yes, please describe

Does the person talk about a person or place that is out of town?

 

Does the person talk about a person who is no longer alive?

 

Does the person talk about visiting a person or place that is out of town?

 

Has the person attempted to visit a person or place out of town without supervision?

 

Can the person drive a car safely

 

Can the person find keys and start a car

 

Does the person desire to drive a car

 

Does the person travel independently using public or private transportation

 

Has the person attempt to travel independently on public or private transportation in the last 6 months

 

Does the person walk or travel a considerable distance from home and return unaided.

 

Does the person get lost or confused easily in an unfamiliar setting?

 

Does the person get lost or confused easily at home/living quarters.

 

 

Please answer the following questions in regards to the last 6 months

 

Yes

No

If Yes, please describe

Person wanders.

 

Person wanders at night.

 

Person wanders during the day

 

Wandering appears goal-oriented

 

Wandering appears random

 

Person seeks out exits or tires to escape from present location

 

Wandering pattern similar to pacing (back and forth)

 

Wandering appears related to a search for a person or place.

 

 

Photograph

 
 

 

 

 


Please obtain two recent photographs that could be released to law enforcement and the media if required.One photograph should be a facial photograph while the second should show the full body. The Alzheimerís Association Safe Return program requests one original photo, passport size or larger

 

Date of Photo:

 

Changes since photo taken:

Is a Videotape available:

 

Location of Videotape: