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Spina Bifida Questionaire
Complex Care Counselling
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Spina Bifida Questionaire
Spina Bifida Questionnaire
Who is completing this form?
Please tell us who is completing the form?
Person who wants counselling
Mother/Father
Social services
Carer
Family member
Other
Other
If one or more people are completing this form multi-select from the answers above.
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GP
GP Practice
Practice postcode
Doctor name
if known
Doctor email
if known
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General Information
Person who wants the counselling
Your name
*
Post Code
Date of Birth
*
00/00/00
Email
Phone
Relationships
Single
Married
Live in Partner
Divorced
Other
Other
Children (under 18)
Yes
No
Employed?
Yes
No
Other
Other
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Your Spina Bifida
Physical Effects
Paraplegia
Quadriplegia
Other
Other
Mobility
Not Needed
Manuel Wheelchair
Advanced Motorised Wheelchair
Crutches
Supporting frame
Tilt-in-space
Standing wheelchair
Standing frame
Other
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
Other
Select your Spina Bifida Classification
Myelomeningocele
Meningocele
Spina bifida occulta
Don’t Know
Other
Other
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Thoughts and Symptoms
How confident are you in making decisions for yourself?
Confident
Ok
Not Confident
Other
Other
Any of these Symptoms?
Tremor
Slowed Movement
Rigid Muscles
Impaired Posture Balance
Loss of Automatic Movements
Speech Changes
Writing Changes
Seizures
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
Seizures
Daily
Weekly
Monthly
A few a year
Other
Other
Seizure Type
Pass out
Stay awake throughout
Don’t know
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Next
Questionnaire Physical
Have painful muscle cramps?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Do you have daily chronic pain?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Worry about falling over in public?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Difficulty holding a drink without spilling it?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Had difficulty washing yourself?
Never
Have Carer Support to do
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Had difficulty dressing yourself?
Never
Have Carer Support to do
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Had difficulty cutting up your food?
Never
Have Carer Support to do
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
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Medical
Any medications?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any Medical Conditions?
None
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
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Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Your Care or Carer
Carer Hours
Part-time
Full-time
Live-in
Other
Other
Are you in care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
In Care Hours
Part-time
Full-time
Live-in
Other
Other
Next
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Questionnaire Psychological
Feel isolated and lonely?
Never
Occasionally
Sometimes
Often
Other
Other
Feel confined to the house?
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 worried about your future?
Never
Occasionally
Sometimes
Often
Other
Other
Avoid situations of eating or drinking in public?
Never
Occasionally
Sometimes
Often
Other
Other
Lack support from friends?
Never
Occasionally
Sometimes
Often
Other
Other
Lack support from your family?
Never
Occasionally
Sometimes
Often
Other
Other
Do people try and take away your independence?
Never
Occasionally
Sometimes
Often
Other
Other
Feel worried by other people’s reaction to you?
Never
Occasionally
Sometimes
Often
Other
Other
Do people over sympathise?
Never
Occasionally
Sometimes
Often
Other
Other
Feel ignored by people?
Never
Occasionally
Sometimes
Often
Other
Other
Do you feel shamed in public?
Never
Occasionally
Sometimes
Often
Other
Other
Do you experience panic attacks?
Yes
No
Sometimes
Have you low self-image?
Yes
No
Sometimes
Do you feel a sense of abandonment?
Yes
No
Sometimes
Do you have suicidal thoughts?
Yes
No
Sometimes
Do you have self-harm thoughts?
Yes
No
Sometimes
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Next
Have you had Funded Sessions in the Past? (Not Disabilityplus)
No
Self-Paid
NHS Funded (CBT Counselling)
Specialist Mental Health Hospital (NHS)
Professional Organisation
Employment Support
School/University
Other
Add each type of counselling from the list above, if more than 1 set of Counselling (NHS example) use other
Counselling?
Self-Paid Year
How many? approx (SP)
NHS Funded Year?
How many? approx (NHS)
Employment Support year?
How many? approx (EAP)
Professional Organisation Year?
How many? approx (PO)
Who?
Other Year?
What Hospital?
How many? approx (other)
What Year?
How many sessions? approx (other)
School, University Year?
How many? approx (education)
Is there anything you would like the counsellor to know ahead of the sessions?
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Preference?
Would you like to add anything?
Counsellor Preference?
Either
Male
Female
Other
Other
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If you are human, leave this field blank.
Submit