Multiple Sclerosis Questionnaire Multiple Sclerosis Questionnaire Name & Contact Details Please tell us who is completing the form? * MyselfCarerMother/FatherFamily memeberSocial servicesOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Please tell us who is completing the form? Your Name? * Client Postcode? * Client Email? * Client Referer Details Are you helping them with the form YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx With person Are you helping with the form YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx With them Have you got permission? YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx From the referred? Referrer name? * Referrer email? * Family/Employment Status? SingleDivorcedLive-In-PartnerMarriedxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Children? YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx under 18? Employed? YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Status Full-TimePart-Timexxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Medically or Physically Able to Work? YesNoOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Medically or Physically Able to Work? Retired or Student? NoStudentRetiredxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx GP Details Surgery Name * Postcode or Town * Dr Name (if Known) Health Medication? NoneAntidepressantsAntipsychoticsAnti-AnxietyHeart MedicationDiabetes MedicationMood StabilisersStimulantsOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Medication? Any Medical Issues? YesNoxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Excluding MS What? (multi-select) Alzheimers Arthritis Asthma Blood Pressure Cancer Infectious Disease Lung Conditions Diabetes Heart Issues Stroke OtherOther Anything to add Medically? About me? My Multiple Sclerosis? * Relapsing-Remitting MS (RRMS)Secondary-Progressive MS (SPMS)Primary-Progressive MS (PPMS)Progressive-Relapsing MS (PRMS)Otherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx My Multiple Sclerosis? Other Disabilities? * None Autism Epilepsy Hearing Loss Medical Illness Sight Loss OtherOther Severity Hearing Loss Mild Moderate Severe Deaf/BSL User OtherOther Sight Loss Mild Moderate Severe Blind OtherOther Epilepsy Severity? Mild Moderate Severe OtherOther What medical illness? What is the other? Mobility & Communication Mobility Device? * Not NeededCrutchesSupporting frameTilt-in-spaceManuel wheelchairStanding wheelchairMotorised wheelchairStanding frameOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Mobility Device? Assistive Technology? * Not NeededElectronic communication boardLow-tech communication boardSpeech-generating deviceEye-tracking deviceTyping and writing devicesHearing AidsCochlear ImplantOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Assistive Technology? Any other? * NoYesOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Any other? Assistive Technology? Not NeededElectronic communication boardLow-tech communication boardSpeech-generating deviceEye-tracking deviceTyping and writing devicesHearing AidsCochlear ImplantOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Assistive Technology? Any other? NoYesOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Any other? Assistive Technology? Not NeededElectronic communication boardLow-tech communication boardSpeech-generating deviceEye-tracking deviceTyping and writing devicesHearing AidsCochlear ImplantOtherxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Assistive Technology? Next