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Neurological Degenerative Diseases
Complex Care Counselling
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Neurological Degenerative Diseases
MND Questionnaire
MND Questionnaire
Identification
First name
*
Surname
*
Home postcode
*
GP name
GP Practice
Practice postcode
*
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Which Degenerative Disease?
Select
*
Parkinson’s
MND
Other
Other
Select
*
Person affected
Carer
Family member
Other
Other
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Parkinson’s Stage
Your Stage
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Stage 1
During this initial stage, the person has mild symptoms that generally do not interfere with daily activities. Tremor and other movement symptoms occur on one side of the body only. Changes in posture, walking and facial expressions occur.
Stage 2
Symptoms start getting worse. Tremor, rigidity and other movement symptoms affect both sides of the body or the midline (such as the neck and the trunk). Walking problems and poor posture may be apparent. The person is able to live alone, but daily tasks are more difficult and lengthier.
Stage 5
This is the most advanced and debilitating stage. Stiffness in the legs may make it impossible to stand or walk. The person is bedridden or confined to a wheelchair unless aided. Around-the-clock care is required for all activities.
Stage 4
At this point, symptoms are fully developed and severely disabling. The person is still able to walk and stand without assistance but may need to ambulate with a cane/walker for safety. The person needs significant help with activities of daily living and is unable to live alone.
Stage 3
Considered mid-stage, loss of balance (such as unsteadiness as the person turns or when he/she is pushed from standing) is the hallmark. Falls are more common. Motor symptoms continue to worsen. Functionally the person is somewhat restricted in his/her daily activities now but is still physically capable of leading an independent life. The disability is mild to moderate at this stage.
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MND Stage
Select type for what each is
MND Type
Amyotrophic Lateral Sclerosis (ALS)
Progressive Bulbar Palsy (PBP)
Progressive Muscular Atrophy (PMA)
Primary Lateral Sclerosis (PLS)
Flail Arm Syndrome
Flail Leg Syndrome
Bulbar-Onset MND
Not sure
Other
Other
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MND Type
Amyotrophic Lateral Sclerosis
This is the most common form of MND. ALS affects both the upper and lower motor neurons. Symptoms include muscle weakness, twitching, and stiffness, which gradually get worse. It can lead to difficulties with speaking, swallowing, and eventually breathing.
Progressive Bulbar Palsy
This type primarily affects the brain stem where the motor neurons that control speech, swallowing, and chewing are located. Symptoms typically include slurred speech and difficulty swallowing.
Progressive Muscular Atrophy (PMA)
This form of MND is less common and primarily affects the lower motor neurons. It is characterised by a gradual weakening of the muscles, particularly in the arms, legs, and mouth.
Primary Lateral Sclerosis
This rare form of MND affects only the upper motor neurons. It leads to muscle stiffness and slowness of movement. PLS progresses more slowly than other types of MND.
Flail Arm Syndrome
Also known as ‘man-in-a-barrel syndrome’, this variant is characterised by weakness predominantly in the upper arms and shoulders with relatively spared lower limbs.
Flail Leg Syndrome
This type is marked by progressive weakness in the legs with relatively spared upper limbs.
Bulbar-Onset MND
Considered mid-stage, loss of balance (such as unsteadiness as the person turns or when he/she is pushed from standing) is the hallmark. Falls are more common. Motor symptoms continue to worsen. Functionally the person is somewhat restricted in his/her daily activities now but is still physically capable of leading an independent life. The disability is mild to moderate at this stage.
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Care
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Are you in care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
Hours
Part-time
Full-time
Live-in
Other
Other
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Carer
Are you the primary caregiver?
Yes
No
Other
Other
What is your Relationship?
Partner
Son/Daughter
Parent
Care Service
Carer (self-employed)
Family Friend
Other
Other
Hours
Part-time
Full-time
Live-in
Other
Other
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Questions
How confident are you in making decisions for yourself?
Confident
Ok
Not Confident
They Cannot
Other
Other
What Symptoms?
Tremor
Slowed Movement
Rigid Muscles
Impaired Posture Balance
Loss of Automatic Movements
Speech Changes
Writing Changes
Memory Changes/Loss
Other
Other
Tremor Severity
Mild
Moderate
Severe
Other
Other
Slowed Movement Severity
Mild
Moderate
Severe
Other
Other
Rigid Muscles Severity
Mild
Moderate
Severe
Other
Other
Impaired Posture/Balance Severity
Mild
Moderate
Severe
Other
Other
Writing Changes Severity
Mild
Moderate
Severe
Other
Other
Loss of Automatic Movements Severity
Mild
Moderate
Severe
Other
Other
Speech Changes Severity
Mild
Moderate
Severe
Other
Other
Other Severity
Mild
Moderate
Severe
Other
Other
Memory Severity
Mild
Moderate
Severe
Other
Other
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Questions about person effected
About person
How confident are they in making decisions for themself?
Confident
Ok
Not Confident
Reliant on Carer
Other
Other
Any Symptoms?
Tremor
Slowed Movement
Rigid Muscles
Impaired Posture Balance
Loss of Automatic Movements
Speech Changes
Writing Changes
Memory Problems
Other
Other
Tremor Severity
Mild
Moderate
Severe
Other
Other
Slowed Movement Severity
Mild
Moderate
Severe
Other
Other
Rigid Muscles Severity
Mild
Moderate
Severe
Other
Other
Impaired Posture/Balance Severity
Mild
Moderate
Severe
Other
Other
Writing Changes Severity
Mild
Moderate
Severe
Other
Other
Speech Changes Severity
Mild
Moderate
Severe
Other
Other
Loss of Automatic Movements Severity
Mild
Moderate
Severe
Other
Other
Other Severity
Mild
Moderate
Severe
Other
Other
Memory Changes Severity
Mild
Moderate
Severe
Other
Other
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Questionnaire
Have difficulty doing the leisure activities which you would like to do?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel isolated and lonely?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel weepy or tearful?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel angry or bitter?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel anxious?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel depressed?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel worried about your future?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel you had to conceal your Parkinson’s from people?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Avoided situations which involve eating or drinking in public?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel embarrassed in public due to having Parkinson’s disease?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel worried by other people’s reaction to you?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have problems with your close personal relationships?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Lack support in the ways you need from your spouse or partner?
Do not have a partner or spouse
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Lack support in the ways you need from your family or close friends?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Unexpectedly fallen asleep during the day?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have problems with your concentration, e.g. when reading or watching TV?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel your memory was bad?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have distressing dreams or hallucinations?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have difficulty with your speech?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel unable to communicate with people properly?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel ignored by people?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have painful muscle cramps or spasms?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Have aches and pains in your joints or body?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel unpleasantly hot or cold?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Signature
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About you (Carer)
Feel isolated and lonely?
Never
Occasionally
Sometimes
Often
Other
Other
Feel overwhelmed?
Never
Occasionally
Sometimes
Often
Other
Other
Feel weepy or tearful?
Never
Occasionally
Sometimes
Often
Other
Other
Feel angry or bitter?
Never
Occasionally
Sometimes
Often
Other
Other
Feel anxious?
Never
Occasionally
Sometimes
Often
Other
Other
Feel depressed?
Never
Occasionally
Sometimes
Often
Other
Other
Feel worried about your future?
Never
Occasionally
Sometimes
Often
Other
Other
Feel worried by other people’s reactions?
Never
Occasionally
Sometimes
Often
Other
Other
Lack support in the ways you need from your spouse or partner?
Never
Occasionally
Sometimes
Often
Other
Other
Lack support in the ways you need from your family or close friends?
Never
Occasionally
Sometimes
Often
Other
Other
Feel ignored by people?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
What would you like help with?
*
Anxiety
Depression
Stress and Worry
Isolation and Loneliness
Coping Strategies
Other
Other
Multi select
What would you like help with?
Fatigue and exhaustion
Emotional fatigue
Sleep disturbances
Changes in appetite
Feelings of guilt
Other
Other
Multi select
Information
What information would you like to give the counsellor ahead of your introduction session?
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