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Muscular Dystrophy Questionaire
Complex Care Counselling
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Muscular Dystrophy Questionaire
Muscular Dystrophy Questionnaire
Who is Completing Form
Please tell us who is completing the form?
*
Myself
Carer
Mother/Father
Family memeber
Social services
Other
I would prefer not to answer question
Please tell us who is completing the form?
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Referer Details
Are you helping them with the form
Yes
No
I would prefer not to answer question
With person
Are you completing the form
Yes
No
I would prefer not to answer question
For them
Have you got permission?
Yes
No
I would prefer not to answer question
From the referred?
Your name?
*
Referrer
Your email?
*
Referrer
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Name & Contact Details
Person who wants counselling
Client Name?
*
Person who wants counselling
Postcode?
*
Date of Birth
*
Email?
*
Client
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Family/Employment
Status?
Single
Divorced
Live-In-Partner
Married
I would prefer not to answer question
Children?
Yes
No
I would prefer not to answer question
under 18?
Employed?
Yes
No
I would prefer not to answer question
Status
Full-Time
Part-Time
I would prefer not to answer question
Medically or Physically Able to Work?
Yes
No
Other
I would prefer not to answer question
Medically or Physically Able to Work?
Retired or Student?
No
Student
Retired
I would prefer not to answer question
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GP Details
Surgery Name
*
Postcode or Town
*
Dr Name (if Known)
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Health
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
I would prefer not to answer question
Medication?
Any Medical Issues?
Yes
No
I would prefer not to answer question
Excluding CP
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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About me?
Your Muscular Dystrophy?
*
Duchenne
Becker
Congenital
Myotonic
Limb-Girdle
Facioscapulohumeral
Emery–Dreifuss
Distal
Oculopharyngeal
Collagen Type VI-Related
Other
Your Muscular Dystrophy?
Other Disabilities?
*
None
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
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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?
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Mobility & Communication
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
I would prefer not to answer question
Mobility Device?
Communication Devices?
*
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
I would prefer not to answer question
Communication Devices?
Any other?
*
No
Yes
Other
I would prefer not to answer question
Any other?
Communication Devices?
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
Communication Devices?
Any other?
No
Yes
Other
I would prefer not to answer question
Any other?
Communication Devices?
Not Needed
Electronic communication board
Low-tech communication board
Speech-generating device
Eye-tracking device
Typing and writing devices
Hearing Aids
Cochlear Implant
Other
I would prefer not to answer question
Communication Devices?
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Next
Carer
Do you have a carer?
No
Yes
Other
I would prefer not to answer question
Do you have a carer?
Does Carer do daily tasks?
Yes, Carer Does
Most of the time
When I ask for help
I would prefer not to answer question
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Carer Reliance?
Personal Hygiene?
I can wash myself
Carer helps me
Carer does for me
Other
I would prefer not to answer question
Personal Hygiene?
Shopping?
I can do shopping
Carer does shopping for me
Only when I need help
Other
I would prefer not to answer question
Shopping?
House cleaning?
I can do it myself
Carer helps when I ask
Carer cleans house
Other
I would prefer not to answer question
House cleaning?
Carer is?
Multiple carers (family)
One carer (family)
Multiple carers (social services)
One carer (social services)
Other
I would prefer not to answer question
Carer is?
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
I would prefer not to answer question
Carer hours?
Anything to add about carer?
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Daily Tasks
Can you do these daily tasks?
Looking after your home?
I can
Struggle
Cannot
Prefer not to answer question
Shopping?
I can
Struggle
Cannot
Prefer not to answer question
Dressing?
I can
Struggle
Cannot
Prefer not to answer question
Cutting up your food?
I can
Struggle
Cannot
Prefer not to answer question
Walking half a mile?
I can
Struggle
Cannot
Prefer not to answer question
Walk 100 yards?
I can
Struggle
Cannot
Prefer not to answer question
Writing clearly?
I can
Struggle
Cannot
Prefer not to answer question
Falling over in public?
I don't worry
I do worry
Prefer not to answer question
Eating in public?
I don't worry
I do worry
Prefer not to answer question
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Do you have daily chronic pain?
No
Few days
Most days
Every day
Other
Prefer not to answer question
Do you have daily chronic pain?
Pain Levels
Severity chronin pain?
Mild
Moderate
Severe
Other
Prefer not to answer question
Severity chronin pain?
Muscle cramps & spasms?
No
Few days
Most days
Every day
Other
Prefer not to answer question
Muscle cramps & spasms?
Severity cramps/spasms?
Mild
Moderate
Severe
Other
Prefer not to answer question
Severity cramps/spasms?
Do you favour one side of your body?
No
Yes
Other
Prefer not to answer question
Do you favour one side of your body?
Unpleasantly hot or cold?
No
Few days
Most days
Every day
Other
Prefer not to answer question
Unpleasantly hot or cold?
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Cognitive
Do you have flashbacks? (if applicable)
No
Few days
Most days
Almost every day
Other
Prefer not to answer question
Do you have flashbacks? (if applicable)
Your flashbacks are:
Mild
Moderately disturbing
Very disturbing
Other
Prefer not to answer question
Your flashbacks are:
Do you have hallucinations
No
Few days
Most days
Almost every day
Other
Prefer not to answer question
Do you have hallucinations
Your hallucinations are:
Mild
Moderately disturbing
Very disturbing
Other
Prefer not to answer question
Your hallucinations are:
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Next
Multi-Select Available
Ableism
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
What Would You Like Help With?
Continued
OCD
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
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Lack support from family?
No
Yes
Sometimes
Prefer not to answer question
Perceptions
All answers based on do you
Lack support from friends?
No
Yes
Sometimes
Prefer not to answer question
Lack support from your partner?
No
Yes
Sometimes
Single
Prefer not to answer question
Feel ignored?
No
Yes
Sometimes
Prefer not to answer question
Anxious in public?
No
Yes
Sometimes
Prefer not to answer question
Worry, people’s reactions to you?
No
Yes
Sometimes
Prefer not to answer question
Feel shamed in public?
No
Yes
Sometimes
Prefer not to answer question
Worry about falling over?
No
Yes
Prefer not to answer question
Personal relationships?
CP does not effect them
CP does effect them
Prefer not to answer question
People take away your independence?
They dont
They try
Always do
I wont let them
Prefer not to answer question
People over sympathising?
They dont
Sometimes, yes
Always do
I wont let them
Prefer not to answer question
Embarrassed in public?
No, I am not
Yes, I am
Sometimes
Prefer not to answer question
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Little interest in doing things?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Depression & Anxiety
“you have or do you”?
Feel down or depressed?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Have little sleep, or sleeping too much?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Feel tired or have little energy?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Feel bad about yourself or let family down?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Trouble concentrating on things?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Feel nervous?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Easily annoyed or irritable?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Do you go along with peoples decsions?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Suicidal thoughts?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Self-harm thoughts?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Worry something awful might happen?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
How confident, making decisions?
Not very confident
Confident
Carer makes decisions for me
Prefer not to answer question
Do you manage your own finances?
Not very confident
Confident
Most Days
No
Prefer not to answer question
Do you worry about your future care?
Never
Few Days
Most Days
Almost Every Day
Prefer not to answer question
Do you undereat?
No
Generally yes
Skip meals
Severely undereat
Bulimia traits
Other
Prefer not to answer question
Do you undereat?
Do you overeat?
No
Generally yes
Severely overeat
Other
Prefer not to answer question
Do you overeat?
Your sleep?
Never sleep
Sleep well
1-2 hours per night
3-5 hours per night
6-8 hours per night
Other
Prefer not to answer question
Your sleep?
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Next
Any, Past Counselling?
*
Yes
No
Prefer not to answer question
NHS Past Counselling?
When? (approx)
Year
How many sessions?
Approx
Any other NHS sessions?
No
Yes
Prefer not to answer question
When? (approx)
Year
How many sessions?
Approx
Any other NHS sessions?
No
Yes
Prefer not to answer question
When? (approx)
Year
How many sessions?
Approx
Experience of NHS Counselling
Good
Did not understand my disability
Poor
Other
Prefer not to answer question
Experience of NHS Counselling
Do you want to add about your counselling experiences?
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Any other counselling?
No
Yes
Prefer not to answer question
Any other counselling?
Self-paid, employer, insurance etc.
Who with?
self-paid, company etc.
Could you add the approx year & how many sessions?
Would you like to add anything?
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Anything you want to add?
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If you are human, leave this field blank.
Submit