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Downs Syndrome Questionaire
Complex Care Counselling
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Downs Syndrome Questionaire
Downs Questionnaire
Who is completing this form?
If person plus another, please select each one who is completing the form
Please tell us who is completing the form?
Person who wants counselling
Carer
Mother/Father
Family memeber
Social services
Other
Other
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Person who wants counselling
Name?
*
PostCode?
*
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GP Details
Surgery Name
Postcode
Dr Name (if Known)
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Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
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Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Medically or Physically Able to Work?
Yes
No
Other
Other
Retired?
Yes
No
Student?
Yes
No
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Aspirations?
What is the aim of counselling?
Multi-select
Facilitating behaviour change
Enhancing coping skills
Facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
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Help With?
What should we concentrate on to start?
Multi-Select
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
General OCD
Relationship OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
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Downs Syndrome Type?
DS Type?
*
Trisomy 21
Translocation Down syndrome
Mosaic Down syndrome
Trisomy 21 Down Syndrome
The most common form of Down syndrome — accounting for roughly 95 per cent of all cases — is trisomy 21 Down syndrome. The condition stems from an error in cell division known as “nondisjunction.” At some point leading up to or at conception, in either the sperm or the egg, one of the parents’ pairs of chromosome 21 failed to separate. So instead of getting one chromosome each from the mother and father, the embryo’s DNA ends up with an extra chromosome in the 21st pair. As the embryo matures and its cells continue to replicate, the extra copy of that 21st chromosome is replicated over and over in every cell.
Translocation Down Syndrome
The genetic science gets even more complicated here. Translocation Down syndrome results when an extra full or partial copy of chromosome 21 is present — just like in trisomy 21. But in these individuals, the extra full or partial chromosome 21 is attached to one of the other 23 chromosomes. So a person with translocation Down syndrome has the usual 46 chromosomes, but one of them is bound to an additional copy of chromosome 21.
Mosaic Down Syndrome
For those with mosaic Down syndrome (also called “mosaicism”), some — but not all — of their cells contain an extra copy of chromosome 21. This is the rarest type of Down syndrome, accounting for 1 to 2 percent of cases, and people with this type may have fewer or less-severe symptoms than those with the two more common types of Down syndrome.
Approx, Intellectual age
Age is the person’s educational age in relation to standard students.
Can this Person Read or Write?
Cannot read
Can read
Cannot write
Can write
Other
Other
Multi-select
Are there any problems with memory?
Poor short term memory
Good short term memory
Poor long term memory
Good long term memory
Other
Other
Multi-select available
Are there any symptoms of Hellers?
Digestive Function
Immune Function
Heart Function
Bone Density
Weight Control
Speech
Other
Other
On a scale of 1 to 10 how social are they?
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Social Situations
Person with Down Syndrome reactions
Feel anxious in public?
No
Yes
Sometimes
Lack support close friends?
No
Yes
Sometimes
Worry about people’s reactions?
No
Yes
Sometimes
Feel ignored by people?
No
Yes
Sometimes
Family Attachments
Not a problem
Reject
Overidialise
Switch Swiftly
Personal relationships?
Reject them
Overidialise
Swiftly interchange
Cope with loss?
Not a problem
Cope well
Struggle
Feel shamed in public?
No
Yes
Sometimes
Isolation? (when stressed)
N/A
Often self isolates (Short period of time)
Often self isolates (extended period)
People over sympathising
No
Yes
Sometimes
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Mobility Assistance
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
Other
Assistive Technology?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
Other
Multi-select
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Carer Questions?
Carer?
No
Yes
Other
Other
Is you carer?
Parent
Partner
Social Services
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
Anything to add about care?
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Health
Any, Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any, medical conditions
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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Any, Additional Disabilities
Do you have any additional disabilities?
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Type?
Absence
Clonic
Focal
Generalised
Tonic-Clonic
Other
Other
Absence
Absence seizures are more common in children than adults and can happen very frequently. During an absence a person becomes unconscious for a short time. They may look blank and stare, or their eyelids might flutter. They will not respond to what is happening around them. If they are walking they may carry on walking but will not be aware of what they are doing.
Clonic
Clonic seizures involve repeated rhythmical jerking movements of one side or part of the body or both sides (the whole body) depending on where the seizure starts. Seizures can start in one part of the brain (called focal motor) or affect both sides of the brain (called generalised clonic).
Focal
As the seizure progresses, a person can experience motor and non-motor symptoms. Some motor symptoms of focal seizures include: muscle twitching jerking spasms repeated movements, like clapping or chewing Non-motor symptoms do not affect how someone moves. However, they may cause confusion or changes in emotions. Some non-motor symptoms of focal seizures include: waves of hot or cold goosebumps lack of movement changes in emotions or thoughts
Generalised
Generalised onset seizures affect both sides of the brain at once and happen without warning. The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure. Unknown onset seizures are sometimes used to describe a seizure if doctors are not sure where in the brain the seizure starts. This may happen if the person was asleep, alone or the seizure was not witnessed. If there is not enough information about a person’s seizure, or if it is unusual, doctors may call it an unclassified seizure.
Tonic Clonic
These are the seizures that most people think of as epilepsy. The person becomes unconscious their body goes stiff and if they are standing up they usually fall backwards. They jerk and shake as their muscles relax and tighten rhythmically.
Other Epilepsy
Best describe what other Epilepsy is
What medical illness?
What is the other?
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NHS Past Counselling?
Any, Past NHS Counselling?
*
Yes
No
Normally CBT (General Counselling)
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions ?
No
Yes
General Counselling (CBT)
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions?
No
Yes
Normally CBT.
Details on how many and year approx
Any, Specialist Counselling
Add as much information as possible.
Experience of NHS Counselling
Good
Did not understand my disability
Poor
Other
Other
Any, Specialist Consultations?
Add as much information as possible.
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Any other counselling?
What other counselling
No
Self-paid
Employer provided
School or university
Insurance
Profesional organisation
Other
Other
More info
Could you add the approx year & how many sessions?
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Brief Summary
Would you like to add anything?
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Select, Sign or Print who has Completed this Form
If carer & person who wants counselling please both sign or print.
Confirmation of person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent.
Signature
Confirmation of carer or person completing this form on behalf of the person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent. I have the authority to complete this form by the person I am supporting.
Signature
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If Carer or Person Responsible
Name
Postcode
Phone
Email
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Submit