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Multiple Sclerosis Questionaire
Complex Care Counselling
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Multiple Sclerosis Questionaire
Multiple Sclerosis Questionnaire
Multiple Sclerosis Questionnaire
Name & Contact Details
Please tell us who is completing the form?
*
Myself
Carer
Mother/Father
Family memeber
Social services
Other
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Please tell us who is completing the form?
Your Name?
*
Client
Postcode?
*
Client
Email?
*
Client
Referer Details
Are you helping them with the form
Yes
No
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With person
Are you helping with the form
Yes
No
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With them
Have you got permission?
Yes
No
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From the referred?
Referrer name?
*
Referrer email?
*
Family/Employment
Status?
Single
Divorced
Live-In-Partner
Married
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Children?
Yes
No
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under 18?
Employed?
Yes
No
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Status
Full-Time
Part-Time
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Medically or Physically Able to Work?
Yes
No
Other
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Medically or Physically Able to Work?
Retired or Student?
No
Student
Retired
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GP Details
Surgery Name
*
Postcode or Town
*
Dr Name (if Known)
Health
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Any Medical Issues?
Yes
No
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Excluding MS
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
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)
Other
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My Multiple Sclerosis?
Other Disabilities?
*
None
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
Severity
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Severity?
Mild
Moderate
Severe
Other
Other
What medical illness?
What is the other?
Mobility & Communication
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
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Mobility Device?
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
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Assistive Technology?
Any other?
*
No
Yes
Other
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Any 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
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Assistive Technology?
Any other?
No
Yes
Other
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Any 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
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Assistive Technology?
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