General Disabilities Questionnaire

General Disabilities Questionnaire

Address & Contact

GP Details


Under 18 & living at home




What Would You Like Help With?

Do you have any of the following?

Please Select? Multi-select available

Disability, Injury or Issue?

Do you have a disability?
Do you have a medical problem?
Is your problem related to food?
Is your problem related to addictions?
Is your problem related to phobias?
Is your problem related to a Injury?
Is your problem related to a neurological issue?
Is your problem related to assault?
Please insert type of assault
Are you in dispute with any authorities or persons?


Is your dispute going to court or litigation?

Assistive Devices

Do you have a carer?

Carer Questions?

Is you carer?
Carer hours?
Any carer problems?
Do you have difficulty looking after your home, e.g., DIY, housework, cooking?

Daily Mobility Questions

Do you have difficulty carrying bags of shopping?
Do you have problems walking half a mile?
Do you have problems walking 100 yards?
Any problems with your speech?
Do you have problems writing clearly?
Do you feel frightened or worried about falling over in public?
Do you have difficulty getting around in public?
Needed someone else to accompany you when you went out?

Pain & Social Anxieties

Do you have daily chronic pain?
Do you have muscle cramps & spasms?
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 feel confined to the house more than you would like?
Do you feel shamed in public?
Do you feel worried about people’s reactions to you?
Do you feel accessible services in public spaces hinder your ability to have a normal life?

Mental Health Questions based on “you have or do you”?

NHS Past Counselling?

Experience of NHS Counselling
What other counselling

Any other counselling? (not NHS paid)

Brief Summary