Rare Genetic Disorders Questionnaire

Rare Genetic Disorders Questionnaire

Who is completing this form?

Please tell us who is completing the form?
If one or more people are completing this form multi-select from the answers above.



What Would You Like Help With?

Address & Contact

Person who would like counselling

Person Referring

The person completing the form

GP Details



Rare Genetic Disorder Type?

Read or Write?
Are there any problems with memory?
Multi-select available

Motor Neuropathy


More information

Can you tell us how you obtained Motor Neuropathy


Select Symptoms

Symptoms lymphoedema

Select Symptoms

Specific to you Symptoms

Specific to you Symptoms

Can you give more information on your condition?

Any, Additional Disabilities

Hearing Loss
Sight Loss
Epilepsy Type?
Best describe what other Epilepsy is



Chronic Pain

Do you have daily chronic pain?
Do you have aches and pains in your joints or body?
Do you have muscle cramps & spasms?
Are the muscle cramps or spasms painful?
Do you favour one side of your body?
Can you feel unpleasantly hot or cold?

Carer Questions?

Do you have a carer?
Is you carer?
Carer hours?
Level of Care?

Daily Living

Do you have difficulty looking after your home, e.g., DIY, housework, cooking?
Do you have difficulty washing?
Do you have difficulty carrying bags of shopping?
Had difficulty dressing?
Do you have problems walking half a mile?
Had problems doing up buttons or shoelaces?
Do you have problems walking 100 yards?
Do you have problems writing clearly?
Needed someone else to accompany you when you went out?
Do you have difficulty cutting up your food?
Do you feel frightened or worried about falling over in public?
Do you have difficulty holding a drink without spilling it?
Do you have difficulty getting around in public?


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 lack support in the ways you need from your partner or spouse?
Do you feel worried about people’s reactions to you?
Do you feel shamed in public?


Do you feel confined to the house more than you would like?
Do you feel you must conceal your disability from people
Do you feel accessible services in public spaces hinder your ability to have a normal life?
Does disability affect your close personal relationships?
Do you feel frightened or worried about falling over in public?
Do you feel people try and take away your independence by over sympathising
Do you feel embarrassed in public?

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

Do you undereat?
Do you overeat?
Do you have hallucinations
Your hallucinations are:
Do you have flashbacks? (if applicable)
Your flashbacks are:

General Questions

NHS Past Counselling?

Experience of NHS Counselling
What other counselling

Any other counselling?