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 OtherOther If one or more people are completing this form multi-select from the answers above. GP GP Practice Practice postcode Doctor name if known Doctor email if known 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 OtherOther Children (under 18) Yes No Employed? Yes No OtherOther Your Spina Bifida Physical Effects Paraplegia Quadriplegia OtherOther Mobility Not Needed Manuel Wheelchair Advanced Motorised Wheelchair Crutches Supporting frame Tilt-in-space Standing wheelchair Standing frame OtherOther 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 OtherOther Select your Spina Bifida Classification Myelomeningocele Meningocele Spina bifida occulta Don’t Know OtherOther Thoughts and Symptoms How confident are you in making decisions for yourself? Confident Ok Not Confident OtherOther Any of these Symptoms? Tremor Slowed Movement Rigid Muscles Impaired Posture Balance Loss of Automatic Movements Speech Changes Writing Changes Seizures OtherOther Tremor Severity Mild Moderate Severe OtherOther Slowed Movement Severity Mild Moderate Severe OtherOther Rigid Muscles Severity Mild Moderate Severe OtherOther Impaired Posture/Balance Severity Mild Moderate Severe OtherOther Writing Changes Severity Mild Moderate Severe OtherOther Loss of Automatic Movements Severity Mild Moderate Severe OtherOther Speech Changes Severity Mild Moderate Severe OtherOther Other Severity Mild Moderate Severe OtherOther Seizures Daily Weekly Monthly A few a year OtherOther Seizure Type Pass out Stay awake throughout Don’t know Next Start Over