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Spinal Cord Injury Questionaire
Complex Care Counselling
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Spinal Cord Injury Questionaire
Spinal Cord Injury Questionnaire
Spinal Cord Injury Questionnaire
You are?
Your Name
*
Post Code
Date Birth
GP Name
If known
Surgery Name
Surgery postcode
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Funding?
Options
Self-funded only
Free funding application
Self fund to start + free funding application
Self-funded
Starts within 14 days: £50 introduction session & then £180 for 3 sessions
Self-funded & application
Free Assessment session & then application made for free funding. Then self pay to continue after assessment session = £180 for 3 sessions
Free funding application
Free assessment session to start. The application for free funding is made after the assessment session. Timescales are generally 12 weeks from assessment. We do everything for you.
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Condition
Injury/Condition
*
Complete SCI
Incomplete SCI
Spinal Muscular Atrophy
Other
Other
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Spinal Dystrophy
Type
Type one
Type Two
Type Three
Type Four
Other
Other
Type 1
Type 1 (SMA I): This is the most severe form of SMA and often manifests in infancy. Individuals with SMA type 1 typically have limited motor function, may require ventilatory support, and have a significantly reduced life expectancy if not treated aggressively.
Type 2
Type 2 (SMA II): SMA type 2 typically presents in early childhood. Individuals with this type generally have the ability to sit unsupported but may have difficulty walking or standing. Life expectancy can vary, and many individuals with type 2 SMA live into adulthood with proper care.
Type 3
Type 3 (SMA III): Also known as Kugelberg-Welander disease, SMA type 3 usually becomes noticeable in late childhood or early adolescence. People with this type can often walk but may experience muscle weakness and motor challenges. Life expectancy is usually normal.
Type 4
Type 4 (SMA IV): This is the adult-onset form of SMA, which becomes apparent in adulthood. Symptoms are milder than in other types, with muscle weakness being the primary issue. Life expectancy is not typically affected.
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Dystrophy Breathing/Coughing
Any Breathing Problems?
No
Yes
Any Coughing Problems
No
Yes
Breathing Severity
Mild
Moderate
Severe
Ventilator
Ventilator Hours (24 hours)
Not needed
When needed
1-4 (hours)
5-10 (hours)
11-15 (hours)
16-24 (hours)
Mental Effects (breathing)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
Coughing Severity
Mild
Moderate
Severe
Mental Effects (coughing)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
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Dystrophy – Physical
Cooking?
Can do myself
Need Carer
Need Carer Mostly
Need Carer Sometimes
Personal Hygiene?
Can do myself
Need Carer
Need Carer Mostly
Need Carer Sometimes
Shopping?
Can do myself
Need Carer
Need Carer Mostly
Need Carer Sometimes
Going outside?
Can do myself
Need Carer
Need Carer Mostly
Need Carer Sometimes
Muscle weekness
No
Mild
Moderate
Severe
Manual dexterity problems
No Issues
Mild
Moderate
Severe
Ability to use your hands in a skilful, coordinated way to grasp and manipulate objects and demonstrate small, precise movements
Chronic fatigue
No
Mild
Moderate
Severe
Bed-bound?
No
Yes
Other
Other
Walking?
No issues
Yes, less 100 yards
Yes, 200 yards
Cannot walk unaided
Can walk with assistive device
Cannot walk
Writing?
Cannot write
Can, legible
Can, not legible
Use assistive writing device
Do you use?
Manuel Wheelchair
Electric Wheelchair
Crutches
Eye Gaze Communicator
Voice software
Other
Other
Tremors
Yes
No
Tremor Severity
Mild
Moderate
Severe
Swallowing?
No issues
Mild
Moderate
Severe
Eating?
No issues
Mild
Moderate
Severe
Speaking?
No issues
Slurred/mild
Slurred/moderate
Slurred/severe
Cannot speak
Scoliosis?
No
Mild
Moderate
Severe
Vision?
Good
Poor
Very Poor
Registered blind
Chronic pain?
No
Yes
As best you can describe chronic pain
Anything to add?
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How?
Due to?
Health problem
Injury
Medical negligence
Genetic Disease
Other
Other
Due to?
Routine planned operation
Complications within operation
Malpractice by surgeon
Other
Other
Health Problem
Brief details of which health problem & how it led to an SCI
What Injury
Road traffic accident
Work related injury
Sports activity
Personal inury
Violent attack
Accident
Other
Other
How did the injury happen?
Brief details
How did the injury happen? (other)
Brief details
Legal proceedings?
None
Engaged solicitor exploring
Ongoing court case
Going to court within 12 months
Other
Other
What year did you have your SCI?
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Your Care or Carer
Do you have carer?
Not Needed
Partner
Sibling
Social Services
Other
Other
Are you in residential care?
No
Supportive Care
Palliative Care
Hospice Care
Other
Other
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Carer
Carer Hours
Part-time
Full-time
Live-in
Other
Other
In Care Hours
Part-time
Full-time
Live-in
Other
Other
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Residential Care
Do you feel the care or carer you receive contributes to your mental health problems?
No
Yes
Sometimes
Prefer not to say
Other
Other
Your Care? (multiple choices)
Happy with my level of care
Feel unsupported
Feel controlled
Prefer not to say
Other
Other
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Next
Questions on Trauma
Flashbacks
No
Few Days
Most Days
Almost Every Day
Weekly
Monthly
Other
Other
Nightmares
No
Few Days
Most Days
Almost Every Day
Other
Other
Repetitive distressing images/sensations
No
Few Days
Most Days
Almost Every Day
Weekly
Monthly
Other
Other
Physical sensations sweating
No
Few Days
Most Days
Almost Every Day
Weekly
Monthly
Other
Other
Physical sensations feeling sick
No
Few Days
Most Days
Almost Every Day
Weekly
Monthly
Other
Other
Physical sensations such as trembling
No
Few Days
Most Days
Almost Every Day
Weekly
Monthly
Other
Other
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Thoughts and Symptoms
How confident are you in making decisions for yourself?
Confident
Ok
Not Confident
Other
Other
My Spinal Cord Injury
Complete
Incomplete
Other
Other
Other
Explain as best you can why you selected “other”.
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Complete
Complete
If all feeling (sensory) and all ability to control movement (motor function) are lost below the spinal cord injury, your injury is called complete.
Mental Effects (sexual function)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
Mental Effects (fertility)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
Breathing Severity
Mild
Moderate
Severe
Mental Effects (breathing)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
Any Breathing or Coughing Problems?
No
Yes
Which? (breathing/coughing)
Breathing
Coughing
Coughing Severity
Mild
Moderate
Severe
Mental Effects (coughing)
Does not effect my mental health
Does effect my mental health (mild)
Does effect my mental health (moderate)
Does effect my mental health (severe)
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Incomplete
Incomplete
If you have some motor or sensory function below the affected area, your injury is called incomplete. There are varying degrees of incomplete injury.
Loss/Pain (multi-select)
Loss of or altered sensation, including the ability to feel heat, cold and touch
Loss of bowel or bladder control
Exaggerated reflex activities or spasms
Changes in fertility
Changes in sexual function, sexual sensitivity
Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal cord
Difficulty breathing, coughing or clearing secretions from your lungs
Other
Other
Spasms
Sudden, involuntary jerking when bending (chest, back)
Sudden, involuntary jerking when extending (straightening)
Hyperactive (overactive) reflexes, such as a muscle spasm when you are lightly touched
Stiff or tight muscles at rest, so that it is difficult to relax or stretch your muscles
Muscle tightness during activity, making it difficult for you to control your movement.
Other
Other
Fertility
Can have children
Cannot have children
Other
Other
Mental Health Effects (fertility)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (fertility)
Explain as best you can
Sexual function
Complete loss
Partial loss
Other
Other
Mental Health Effect (sexual function)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Why other? (sexual function)
Explain as best you can
Pain
Mild
Moderate
Severe
Other
Other
Frequency (pain) (7 days)
Few days
Most days
Almost every day
Other
Other
Pain where?
Back
Neck
Legs
Hips
Feet
Hands
Other
Other
Mental Health Effect (pain)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
Breathing Severity
Mild
Moderate
Severe
Other
Other
Frequency (breathing) (7 days)
Few days
Most days
Almost every day
Other
Other
Mental Health Effect (breathing)
Does not contribute
Contributes (mild)
Contributes (severe)
Other
Other
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Questionnaire Psychological
Feel isolated and lonely?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel confined to the house more than you would like?
Never
Occasionally
Sometimes
Often
Always or cannot do at all
Other
Other
Feel worried about your future?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel weepy or tearful?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel angry or bitter?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel depressed?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel anxious?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel embarrassed in public due to having an SCI?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Avoided situations which involve eating or drinking in public?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel worried by other people’s reaction to you?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Have problems with your close personal relationships?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Lack support in the ways you need from your spouse or partner?
Do not have a partner or spouse
Spouse/Partner left due to SCI
Never
Occasionally
Sometimes
Often
Always
Other
Other
Lack support in the ways you need from your family or close friends?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Do you unexpectedly fall asleep during the day?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel unable to communicate with people properly?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel ignored by people?
Never
Occasionally
Sometimes
Often
Always
Other
Other
Feel your memory is bad?
Never
Occasionally
Sometimes
Often
Other
Other
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Next
What would you like help with?
Checkboxes
Anger
Generalised Anxiety
Social Anxiety
Stress
Discrimination
PTSD
Eating Disorder
Disruptive behaviours
Self-harm
Suicidal thoughts
Neurodevelopment disorders
Depression
Emotional problems
OCD traits
Phobias
ADHD traits
Paranoia
Psychosis
Other
Other
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Other Info
Would you like to add anything?
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