Toggle navigation
Home
Brittle Bones (OI) & Osteoporosis Questionaire
Complex Care Counselling
Home
/
Brittle Bones (OI) & Osteoporosis Questionaire
Brittle Bones Questionnaire
The Questionnaire
Why?
Osteogenesis imperfecta (brittle bones) is complex and has many variations. This questionnaire attempts to give your specialist a general understanding of the physical and psychological impact OI has on you.
Confidential
All information within this questionnaire is private and confidential, it will not be shared with anyone apart from your counsellor.
Confidential
The exception to this rule is if DisabilityPlus has asked you to complete the questionnaire for a NHS application for free funding. In this instance the information within it will be used to submit the application for you.
Section Buttons
Who is completing this form?
Please tell us who is completing the form?
Person who wants counselling
Carer
Mother/Father
Family memeber
Social services
Other
Other
If one or more people are completing this form multi-select from the answers above.
Section Buttons
Next
Address & Contact
Your Name?
*
PostCode?
*
Section Buttons
GP Details
Surgery Name
Postcode
Dr Name (if Known)
Section Buttons
Home?
Relationship?
Single
Divorced
Live-In-Partner
Married
Children?
Yes
No
Section Buttons
Employment?
Employed?
Yes
No
Status
Full-Time
Part-Time
Are You Medically or Physically Able to Work?
Yes
No
Other
Other
Are You Retired?
Yes
No
Are you a student?
Yes
No
Section Buttons
Aspirations?
Multi-select
Facilitating behaviour change
Enhancing coping skills
facilitating your potential
Development of self-worth
Improving relationships
Reduce anger
Reduce negative feeling and thoughts
Explore broad set of issues
Reduce or remove addictions
Establish and maintain relationships
Remove or reduce negative cycles
Other
Other
Section Buttons
What Would You Like Help With?
Multi-Select Available
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
OCD
Continued
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
Section Buttons
Next
Brittle Bones Type?
Classifications
*
Type 1
Type 2
Type 3
Type 5
Osteoporosis
None of the above
Other
Other
Type 1
Type I: This is the mildest and most common form of OI. Type I leads to broken bones (bone fractures) or muscle weakness. It doesn’t cause any bone deformity.
Type 2
Type II: People with Type II often can’t breathe. Type II causes multiple broken bones even before birth.
Type 3
Type III: People with type 3 often have broken bones at birth. Type III often leads to severe physical disabilities.
Type 5
Type IV: Bones may break easily. Usually, people with this type have their first bone break before puberty. People with Type IV may have mild to moderate bone deformity.
Osteoporosis
Osteoporosis is a health condition that weakens bones, making them fragile and more likely to break. It develops slowly over several years and is often only diagnosed when a fall or sudden impact causes a bone to break (fracture).
Any current broken bones?
No
Wrist
Hip
Spinal (Vertebrae)
Other
Other
Are any of these conditions permanent
No
Wrist
Hip
Spinal (Vertebrae)
Other
Other
Osteoporosis Severity
Mild
Moderate
Severe
Other
Other
Do you know the cause of your Osteoporosis?
Section Buttons
Mobility Assistance Devices
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised 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
Multi-select
Section Buttons
Daily Living
Do you have difficulty looking after your home, e.g., DIY, housework, cooking?
No
Yes
Cannot do
Do you have difficulty washing?
No
Yes
Cannot do
Do you have difficulty carrying bags of shopping?
No
Yes
Cannot do
Had difficulty dressing?
No
Yes
Cannot do
Do you have problems walking half a mile?
No
Yes
Carer Assistance
Had problems doing up buttons or shoelaces?
No
Yes
Carer assistance
Do you have problems walking 100 yards?
No
Yes
Cannot do
Do you have problems writing clearly?
No
Yes
Needed someone else to accompany you when you went out?
No
Yes
Sometimes
Do you have difficulty cutting up your food?
No
Yes
Carer assistance
Do you feel frightened or worried about falling over in public?
No
Yes
Sometimes
Do you have difficulty holding a drink without spilling it?
No
Yes
Sometimes
Do you have difficulty getting around in public?
No
Yes – poor accessibility
Yes – socially anxious
Section Buttons
Carer Questions?
Do you have a carer?
No
Yes
Other
Other
Is you carer?
Parent
Partner
Social Services
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
Any carer problems?
No – excellent care
No – good care
General poor care
Multiple carers
Personality clash
Other
Other
Anything to add about carer?
Section Buttons
Next
Any, Additional Disabilities
Do you have any additional disabilities?
No
Autism
Arthritis
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
Arthritis
Mild
Moderate
Severe
Other
Other
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Type?
Absence
Clonic
Focal
Generalised
Tonic-Clonic
Other
Other
Absence
Absence seizures are more common in children than adults and can happen very frequently. During an absence a person becomes unconscious for a short time. They may look blank and stare, or their eyelids might flutter. They will not respond to what is happening around them. If they are walking they may carry on walking but will not be aware of what they are doing.
Clonic
Clonic seizures involve repeated rhythmical jerking movements of one side or part of the body or both sides (the whole body) depending on where the seizure starts. Seizures can start in one part of the brain (called focal motor) or affect both sides of the brain (called generalised clonic).
Focal
As the seizure progresses, a person can experience motor and non-motor symptoms. Some motor symptoms of focal seizures include: muscle twitching jerking spasms repeated movements, like clapping or chewing Non-motor symptoms do not affect how someone moves. However, they may cause confusion or changes in emotions. Some non-motor symptoms of focal seizures include: waves of hot or cold goosebumps lack of movement changes in emotions or thoughts
Generalised
Generalised onset seizures affect both sides of the brain at once and happen without warning. The person will be unconscious (except in myoclonic seizures), even if just for a few seconds and afterwards will not remember what happened during the seizure. Unknown onset seizures are sometimes used to describe a seizure if doctors are not sure where in the brain the seizure starts. This may happen if the person was asleep, alone or the seizure was not witnessed. If there is not enough information about a person’s seizure, or if it is unusual, doctors may call it an unclassified seizure.
Tonic Clonic
These are the seizures that most people think of as epilepsy. The person becomes unconscious their body goes stiff and if they are standing up they usually fall backwards. They jerk and shake as their muscles relax and tighten rhythmically.
Other Epilepsy
Best describe what other Epilepsy is
What medical illness?
What is the other?
Section Buttons
Health
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Any Medical Issues apart from OI?
*
Yes
No
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
Section Buttons
Next
General Questions
This section gives your counsellor a understanding of how OI effects your daily living. This section is optional, please skip if you would prefer not to answer.
Do you undereat?
No
Generally yes
Skip meals
Severely undereat
Bulimia traits
Other
Other
Do you overeat?
No
Generally yes
Severely overeat
Other
Other
Do you have hallucinations
No
Few days
Most days
Almost every day
Other
Other
Your hallucinations are:
Mild
Moderately disturbing
Very disturbing
Other
Other
Do you have flashbacks? (if applicable)
No
Few days
Most days
Almost every day
Other
Other
Your flashbacks are:
Mild
Moderately disturbing
Very disturbing
Other
Other
Section Buttons
Pain
Do you have daily chronic pain?
No
Yes
Other
Other
Do you have aches and pains in your joints or body?
No
Yes
Other
Other
Do you have muscle cramps & spasms?
No
Yes
Other
Other
Are the muscle cramps or spasms painful?
No
Yes
Other
Other
Do you favour one side of your body?
No
Yes
Other
Other
Can you feel unpleasantly hot or cold?
No
Yes
Other
Other
Section Buttons
Next
Anxieties
Do you feel anxious in public?
No
Yes
Sometimes
Do you lack support in the ways you need from family or close friends
No
Yes
Sometimes
Do you feel ignored by people?
No
Yes
Sometimes
Do you lack support in the ways you need from your partner or spouse?
No
Yes
Sometimes
Do you feel worried about people’s reactions to you?
No
Yes
Sometimes
Do you feel shamed in public?
No
Yes
Sometimes
Do you feel confined to the house more than you would like?
No
Yes
Sometimes
Do you feel you must conceal your disability from people
No
Yes
Sometimes
Obvious
Do you feel accessible services in public spaces hinder your ability to have a normal life?
No
Yes
Sometimes
Does disability affect your close personal relationships?
No
Yes
Sometimes
Do you feel frightened or worried about falling over in public?
No
Yes
Do you feel people try and take away your independence by over sympathising
No
Yes
Sometimes
Do you feel embarrassed in public?
No
Yes
Sometimes
Section Buttons
Next
NHS Past Counselling?
Any, Past Counselling?
*
Yes
No
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions ?
No
Yes
Approx, how many years ago?
Approx, how many sessions?
Any other NHS sessions??
No
Yes
Details on how many and year approx
Experience of NHS Counselling
Good
Did not understand my disability
Poor
Other
Other
Section Buttons
Any other counselling?
What other counselling
No
Self-paid
Employer provided
School or university
Insurance
Profesional organisation
Other
Other
Could you add the approx year & how many sessions?
Section Buttons
Next
Risk Assessment
Do you ever feel like life is not worth living?
No
Few Days
Most Days
Almost Every Days
Have you ever tried to commit suicide?
No
Yes
Other
Other
Approx how many years ago did you try to take your life?
How often do you have suicidal thoughts?
Few Days
Most Days
Almost Every Days
Do you know how to end your life?
No
Yes
Other
Other
Have you made plans to end your life?
No
Yes
Other
Other
Do you ever feel like self harming?
No
Yes
Other
Other
Have you self harmed in the past?
No
Yes
Other
Other
Approx how many years ago did you self harm?
Other, do you ever feel like self-harming?
Best describe your thoughts
Section Buttons
Brief Summary
Would you like to add anything?
Section Buttons
Confirmation
Confirmation of person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent.
Signature
Confirmation of carer or person completing this form on behalf of the person who would like counselling
I confirm the information in this form is true to the best of my knowledge. I understand the information within this document will not be shared with any organisation or person without my written consent. I have the authority to complete this form by the person I am supporting.
Signature
Section Buttons
If Carer or Person Responsible
Name
Postcode
Phone
Email
Section Buttons
If you are human, leave this field blank.
Submit