If you consent to completing this survey please tick this box *

Please give your age in years *

Please give your gender *

Please state the area of B&NES you live in *

I am a person with dementia or memory problems

I am a carer or friend of a person with dementia or memory problems and I am filling in this questionnaire on their behalf.

I work with people with dementia or memory problems and I am filling in this form on their behalf.

None of the above

What makes it more difficult for you to do these things?

Are there things you used to do but have stopped doing? e.g. shopping, going to the hairdressers/barbers, social events.

If so, why have you stopped doing them?

What might help you to start doing them again?

Are there new things that you would like to be able to do in your community?

If so, what do you feel is stopping you?

What might help you to start doing them?

Have you seen the B&NES Guide to Services for People with Dementia? If yes, where did you get it?

Do you use the Internet? If yes, what websites do you use?

Finally, what do you think could be done to make your community more dementia-friendly?

Name

Telephone Number

Email