Ehlers-Danlos Syndrome Questionaire

Complex Care Counselling

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Why questionaire? this questionnaire removes the need to ask these questions in the form in the first session. This means you can start your counselling assessment or self-paid counselling talking about yourself rather than answering questions about your EDS.

All information you put into this questionnaire is private and confidential, it will only be shared with your specialist counsellor. If you have been asked to complete this for NHS funding application the information will form part of the NHS application for free funding & be shared with the NHS funding panel.

This questionnaire should take no more than 4 minutes to complete.

Ehlers Danlos Syndrome

Ehlers Danlos Syndrome?

EDS Symptoms

Joint Hyper Mobility
Loose, unstable joints that dislocate easily
Velvety skin that is stretchy
Wounds that are slow to heal and leave wide scars
Joint pain and clicking joints
Skin that bruises easily
Heartburn
Constipation
Dizziness and an increased heart rate after standing up
Mitral valve problems
Organ prolapse
Urinary incontinence
Visible small blood vessels
Curvature of the spine
Fragile eyes
Constipation

Any, Additional Disabilities

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

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.

Address & Contact

Home?

Living at home

Employment?

Aspirations?

Multi-select

What Would You Like Help With?

Mobility

Multi-select

Daily Living & Social Settings

Do you have difficulty looking after your home, e.g., DIY, housework, cooking?
Do you have difficulty carrying bags of shopping?
Do you have problems walking 100 yards?
Do you have problems walking half a mile?
Do you have problems writing clearly?
Needed someone else to accompany you when you went out?
Do you feel frightened or worried about falling over in public?
Do you have difficulty getting around in public?

Carer Questions?

Do you have a carer?
Is you carer?
Carer hours?
Quality of care?

Health

Pain

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?

Anxieties

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

Anger/Lashing out
Any, problems with food?
Sleep?
Do you worry about your health?
Do you worry about financial future?
How confident are you in making decisions?
Do you worry about your future care?
How stressed are you?

NHS Past Counselling?

Approx
approx
Approx
approx
Approx
approx
Have you seen a specialist consultant?
Year and what happened
Experience of NHS Care you have received?
Can you give more info?
Experience of NHS Counselling
Can you give more info?

Any other counselling?

What other counselling

Assessment

approx
approx
Best describe your thoughts

Brief Summary

Select, Sign or Print who has Completed this Form

If carer & person who wants counselling please both sign or print.

If Carer or Person Responsible