Spina Bifida 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.

GP

if known
if known

General Information

Person who wants the counselling
00/00/00
Children (under 18)

Your Spina Bifida

Physical Effects
Mobility
Assistive Technology
Select your Spina Bifida Classification

Thoughts and Symptoms

How confident are you in making decisions for yourself?
Any of these Symptoms?
Tremor Severity
Slowed Movement Severity
Rigid Muscles Severity
Impaired Posture/Balance Severity
Writing Changes Severity
Loss of Automatic Movements Severity
Speech Changes Severity
Other Severity
Seizures
Seizure Type

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