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 person’s 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/Alzheimer’s Questions

Dementia Diagnosis: (Alzheimer’s, Vascular, Parkinson’s, 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 “accidents”				‘	‘	‘
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 Alzheimer’s Associations’ Safe Return program	‘	‘	If yes, please list ID #

Subject’s 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 subject’s 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 person’s 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 Alzheimer’s 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: