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 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. Condition Injury/Condition * Complete SCI Incomplete SCI Spinal Muscular Atrophy OtherOther Spinal Dystrophy Type Type one Type Two Type Three Type Four OtherOther 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. 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) 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 OtherOther 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 OtherOther 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? How? Due to? Health problem Injury Medical negligence Genetic Disease OtherOther Due to? Routine planned operation Complications within operation Malpractice by surgeon OtherOther 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 OtherOther 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 OtherOther What year did you have your SCI? Your Care or Carer Do you have carer? Not Needed Partner Sibling Social Services OtherOther Are you in residential care? No Supportive Care Palliative Care Hospice Care OtherOther Carer Carer Hours Part-time Full-time Live-in OtherOther In Care Hours Part-time Full-time Live-in OtherOther Residential Care Do you feel the care or carer you receive contributes to your mental health problems? No Yes Sometimes Prefer not to say OtherOther Your Care? (multiple choices) Happy with my level of care Feel unsupported Feel controlled Prefer not to say OtherOther If you are human, leave this field blank. Next Start Over