Darganfod Dementia Sir y Fflint/Discovering Dementia Enquiry form

Mae’r ffurflen hon i chi ei llenwi os ydych yn byw gyda dementia. Gall eich person cefnogi eich helpu i’w llenwi os oes angen, ond gwnewch yn siŵr bod yr atebion yn ymwneud â chi.

This form is for you to complete if you are living with dementia. Your support person can help you to fill it in if needed, but please make sure the answers are about you.
Manylion y person sy’n byw gyda Dementia / Details of person living with Dementia
Enw /Name

Enw Cyntaf / First NameCyfenw / Last Name
Dyddiad Geni /Date of Birth

MonthDayYear
Date
Cyfeiriad /Address

Cyfeiriad Stryd / Street Address

Cyfeiriad Stryd Llinell 2 / Street Address Line 2

Dinas / CitySir/Talaith - /State / Province

Cod Post / Postal Code
Hoffwn gael fy ychwanegu at Restr Bostio Darganfod Dementia / I'd like to be added to the Discovering Dementia Mailing List

Ie / YesNa / No

Pwy yw’r person gorau i siarad gyda hwy? / Who's the best person for us to speak to?

Tudalen 2 o 3 / Page 2 of 3
Enw / Name

Enw Cyntaf / First NameCyfenw / Last Name
Beth yw eu perthynas â chi? Neu ai dyma chi ? / What is their relationship to you? Or is it you?
E-Bost / Email
example@example.com
Rhif Ffôn / Phone Number
Rhowch rif ffôn dilys Please enter a valid phone number.
Y ffordd orau i siarad â mi / The best way to speak to me

Ffôn / PhoneWyneb yn wyneb / Face to faceE-bost / Email

Ychydig yn rhagor o wybodaeth am y person yn byw gyda Dementia. / Some more info about the person living with Dementia.

Tudalen 3 o 3 / Page 3 of 3
Pwy yw’r bobl sy’n chwarae rhan bwysig yn eich bywyd? / Who are the people that play an important part in your life?
A oes unrhyw beth y gallwn eich cefnogi chi (neu eich teulu) ag ef ar hyn o bryd? / Is there anything we can support you (or your family) with at the moment?
Unrhyw beth arall i’w ddweud wrthym? / Anything else to tell us?
Should be Empty:

Manylion y person sy’n byw gyda Dementia / Details of person living with Dementia