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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.
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
Other
Other
Children (under 18)
Yes
No
Employed?
Yes
No
Other
Other
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
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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