Spinal Cord Injury Questionnaire

You are?

How SCI?

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

Questions on Trauma

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

Your Care or Carer

Do you have carer?
Are you in care?
Carer Hours
In Care Hours
Your Carer? (multiple choices)
Your Care? (multiple choices)
Do you feel the care or carer you receive contributes to your mental health problems?

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”.


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


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

Mood Assessment

Are your relationships intense, and unstable, and alternate between the extremes of over-idealising and undervaluing people who are important to you?
Do your emotions change quickly, and you experience intense episodes of sadness, irritability, and anxiety or panic attacks?
Do you engage in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning, or hitting?
Is your level of anger often inappropriate, intense, and challenging to control.
Have you a persistent unstable image or sense of self, or of who or what you believe in?
Do you have suspicious ideas, or paranoia ( believing that others are plotting to cause you harm)?
Do you experience under stress episodes that other people, or the situation is somewhat unreal
Now or in the past, engage in two or more self-damaging acts such as inappropriate sexual conduct, substance abuse, reckless driving, and binge eating
Do you engage in frantic efforts to avoid real or imagined abandonment by people who are close to you?

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?

Other Info

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