Ataxia Questionnaire

Ataxia Questionnaire

Who is completing this form?

Please tell us who is completing the form?
If one or more people are completing this form multi-select from the answers above.

Contact details of person completing this form

Your Contact Details (person who wants counselling)

GP Details





What Would You Like Help With?

Ataxia Type?

Acquired Causes?
Multi-Select if needed

Carer Questions?

Do you have a carer?
Is you carer?
Carer hours?
Any carer problems?


Do you have difficulty looking after your home, e.g., DIY, housework, cooking?
Do you have difficulty washing?
Do you have difficulty carrying bags of shopping?
Had difficulty dressing?
Do you have problems walking half a mile?
Had problems doing up buttons or shoelaces?
Do you have problems walking 100 yards?
Do you have problems writing clearly?
Needed someone else to accompany you when you went out?
Do you have difficulty cutting up your food?
Do you feel frightened or worried about falling over in public?
Do you have difficulty holding a drink without spilling it?
Do you have difficulty getting around in public?

Any, Additional Disabilities

Hearing Loss
Sight Loss
Epilepsy Type?
Best describe what other Epilepsy is

Your Symptoms

Any, Muscle Stiffness in Legs
Any, Muscle Stiffness Arms
Any, Walking Problems?
Any Speech Problems?
Any, Writing Problems
Any, Balance Problems
Any, Swallowing Problems?
Any, Cognitive Issues?



Do you have daily chronic pain?
Do you have aches and pains in your joints or body?
Do you have muscle cramps & spasms?
Are the muscle cramps or spasms painful?
Do you favour one side of your body?
Can you feel unpleasantly hot or cold?


Do you feel anxious in public?
Do you lack support in the ways you need from family or close friends
Do you feel ignored by people?
Do you lack support in the ways you need from your partner or spouse?
Do you feel worried about people’s reactions to you?
Do you feel shamed in public?
Do you feel confined to the house more than you would like?
Do you feel you must conceal your disability from people
Do you feel accessible services in public spaces hinder your ability to have a normal life?
Does disability affect your close personal relationships?
Do you feel frightened or worried about falling over in public?
Do you feel people try and take away your independence by over sympathising
Do you feel embarrassed in public?

General Questions

Do you undereat?
Do you overeat?
Do you have hallucinations
Your hallucinations are:
Do you have flashbacks? (if applicable)
Your flashbacks are:

NHS Past Counselling?

Experience of NHS Counselling

Any other counselling?

What other counselling


Best describe your thoughts

Brief Summary

Sign or Type