Spinal Cord Injury Questionnaire

Spinal Cord Injury Questionnaire

You are?

If known

Funding?

Options

Condition

Injury/Condition

Spinal Dystrophy

Type

Dystrophy Breathing/Coughing

Any Breathing Problems?
Any Coughing Problems
Breathing Severity
Ventilator Hours (24 hours)
Mental Effects (breathing)
Coughing Severity
Mental Effects (coughing)

Dystrophy – Physical

Cooking?
Personal Hygiene?
Shopping?
Going outside?
Muscle weekness
Manual dexterity problems
Ability to use your hands in a skilful, coordinated way to grasp and manipulate objects and demonstrate small, precise movements
Chronic fatigue
Bed-bound?
Walking?
Writing?
Do you use?
Tremors
Tremor Severity
Swallowing?
Eating?
Speaking?
Scoliosis?
Vision?
Chronic pain?

How?

Due to?
Due to?
Brief details of which health problem & how it led to an SCI
What Injury
Brief details
Brief details
Legal proceedings?

Your Care or Carer

Do you have carer?
Are you in residential care?

Carer

Carer Hours
In Care Hours

Residential Care

Do you feel the care or carer you receive contributes to your mental health problems?
Your Care? (multiple choices)

Questions on Trauma

Flashbacks
Nightmares
Repetitive distressing images/sensations
Physical sensations sweating
Physical sensations feeling sick
Physical sensations such as trembling

Thoughts and Symptoms

How confident are you in making decisions for yourself?
My Spinal Cord Injury
Explain as best you can why you selected “other”.

Complete

Mental Effects (sexual function)
Mental Effects (fertility)
Breathing Severity
Mental Effects (breathing)
Any Breathing or Coughing Problems?
Which? (breathing/coughing)
Coughing Severity
Mental Effects (coughing)

Incomplete

Loss/Pain (multi-select)
Spasms
Fertility
Mental Health Effects (fertility)
Explain as best you can
Sexual function
Mental Health Effect (sexual function)
Explain as best you can
Pain
Frequency (pain) (7 days)
Pain where?
Mental Health Effect (pain)
Breathing Severity
Frequency (breathing) (7 days)
Mental Health Effect (breathing)

Questionnaire Psychological

Feel isolated and lonely?
Feel confined to the house more than you would like?
Feel worried about your future?
Feel weepy or tearful?
Feel angry or bitter?
Feel depressed?
Feel anxious?
Feel embarrassed in public due to having an SCI?
Avoided situations which involve eating or drinking in public?
Feel worried by other people’s reaction to you?
Have problems with your close personal relationships?
Lack support in the ways you need from your spouse or partner?
Lack support in the ways you need from your family or close friends?
Do you unexpectedly fall asleep during the day?
Feel unable to communicate with people properly?
Feel ignored by people?
Feel your memory is bad?

What would you like help with?

Checkboxes

Other Info