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Multiple Sclerosis Questionaire
Complex Care Counselling
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Multiple Sclerosis Questionaire
Multiple Sclerosis Questionnaire
Name & Contact Details
Please tell us who is completing the form?
*
Myself
Carer
Mother/Father
Family memeber
Social services
Other
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Please tell us who is completing the form?
Your Name?
*
Client
Postcode?
*
Client
Email?
*
Client
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Referer Details
Are you helping them with the form
Yes
No
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With person
Are you helping with the form
Yes
No
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With them
Have you got permission?
Yes
No
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From the referred?
Referrer name?
*
Referrer email?
*
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Family/Employment
Status?
Single
Divorced
Live-In-Partner
Married
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Children?
Yes
No
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under 18?
Employed?
Yes
No
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Status
Full-Time
Part-Time
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Medically or Physically Able to Work?
Yes
No
Other
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Medically or Physically Able to Work?
Retired or Student?
No
Student
Retired
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GP Details
Surgery Name
*
Postcode or Town
*
Dr Name (if Known)
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Health
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
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Medication?
Any Medical Issues?
Yes
No
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Excluding MS
What? (multi-select)
Alzheimers
Arthritis
Asthma
Blood Pressure
Cancer
Infectious Disease
Lung Conditions
Diabetes
Heart Issues
Stroke
Other
Other
Anything to add Medically?
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About me?
My Multiple Sclerosis?
*
Relapsing-Remitting MS (RRMS)
Secondary-Progressive MS (SPMS)
Primary-Progressive MS (PPMS)
Progressive-Relapsing MS (PRMS)
Other
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My Multiple Sclerosis?
Other Disabilities?
*
None
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
Other
Other
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Severity
Hearing Loss
Mild
Moderate
Severe
Deaf/BSL User
Other
Other
Sight Loss
Mild
Moderate
Severe
Blind
Other
Other
Epilepsy Severity?
Mild
Moderate
Severe
Other
Other
What medical illness?
What is the other?
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Mobility & Communication
Mobility Device?
*
Not Needed
Crutches
Supporting frame
Tilt-in-space
Manuel wheelchair
Standing wheelchair
Motorised wheelchair
Standing frame
Other
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Mobility Device?
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
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Assistive Technology?
Any other?
*
No
Yes
Other
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Any 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
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Assistive Technology?
Any other?
No
Yes
Other
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Any 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
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Assistive Technology?
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Next
Carer
Do you have a carer?
No
Yes
Other
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Do you have a carer?
Does Carer do daily tasks?
Yes, Carer Does
Most of the time
When I ask for help
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Carer Reliance?
Personal Hygiene?
I can wash myself
Carer helps me
Carer does for me
Other
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Personal Hygiene?
Shopping?
I can do shopping
Carer does shopping for me
Only when I need help
Other
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Shopping?
House cleaning?
I can do it myself
Carer helps when I ask
Carer cleans house
Other
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House cleaning?
Carer is?
Multiple carers (family)
One carer (family)
Multiple carers (social services)
One carer (social services)
Other
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Carer is?
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
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Carer hours?
Anything to add about carer?
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Daily Tasks
Can you do these daily tasks?
Looking after your home?
I can
Struggle
Cannot
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Shopping?
I can
Struggle
Cannot
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Dressing?
I can
Struggle
Cannot
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Cutting up your food?
I can
Struggle
Cannot
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Walking half a mile?
I can
Struggle
Cannot
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Walk 100 yards?
I can
Struggle
Cannot
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Writing clearly?
I can
Struggle
Cannot
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Falling over in public?
I don't worry
I do worry
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Eating in public?
I don't worry
I do worry
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Pain Levels
Do you have daily chronic pain?
No
Few days
Most days
Every day
Other
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Do you have daily chronic pain?
Severity chronin pain?
Mild
Moderate
Severe
Other
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Severity chronin pain?
Muscle cramps & spasms?
No
Few days
Most days
Every day
Other
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Muscle cramps & spasms?
Severity cramps/spasms?
Mild
Moderate
Severe
Other
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Severity cramps/spasms?
Do you favour one side of your body?
No
Yes
Other
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Do you favour one side of your body?
Unpleasantly hot or cold?
No
Few days
Most days
Every day
Other
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Unpleasantly hot or cold?
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Cognitive
Do you have flashbacks? (if applicable)
No
Few days
Most days
Almost every day
Other
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Do you have flashbacks? (if applicable)
Your flashbacks are:
Mild
Moderately disturbing
Very disturbing
Other
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Your flashbacks are:
Do you have hallucinations
No
Few days
Most days
Almost every day
Other
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Do you have hallucinations
Your hallucinations are:
Mild
Moderately disturbing
Very disturbing
Other
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Your hallucinations are:
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Next
What Would You Like Help With?
Multi-Select Available
Ableism
Addictions
Anger
Anxiety
Body Dysmorphia
Chronic Fatigue Syndrome
Chronic Pain
Depression
Dissociative Disorders
Health Anxiety
Fibromyalgia
Continued
OCD
Psychosis
Panic Disorder
Personality Disorder
Phobias
PTSD
Social Anxiety
Stress
Suicidal Thought
Self-Harm Thoughts
Other
Other
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Perceptions
All answers based on do you
Lack support from family?
No
Yes
Sometimes
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Lack support from friends?
No
Yes
Sometimes
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Lack support from your partner?
No
Yes
Sometimes
Single
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Feel ignored?
No
Yes
Sometimes
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Anxious in public?
No
Yes
Sometimes
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Worry, people’s reactions to you?
No
Yes
Sometimes
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Feel shamed in public?
No
Yes
Sometimes
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Worry about falling over?
No
Yes
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Personal relationships?
CP does not effect them
CP does effect them
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People take away your independence?
They dont
They try
Always do
I wont let them
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People over sympathising?
They dont
Sometimes, yes
Always do
I wont let them
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Embarrassed in public?
No, I am not
Yes, I am
Sometimes
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Depression & Anxiety
“you have or do you”?
Little interest in doing things?
Never
Few Days
Most Days
Almost Every Day
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Feel down or depressed?
Never
Few Days
Most Days
Almost Every Day
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Have little sleep, or sleeping too much?
Never
Few Days
Most Days
Almost Every Day
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Feel tired or have little energy?
Never
Few Days
Most Days
Almost Every Day
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Feel bad about yourself or let family down?
Never
Few Days
Most Days
Almost Every Day
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Trouble concentrating on things?
Never
Few Days
Most Days
Almost Every Day
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Feel nervous?
Never
Few Days
Most Days
Almost Every Day
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Easily annoyed or irritable?
Never
Few Days
Most Days
Almost Every Day
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Do you go along with peoples decsions?
Never
Few Days
Most Days
Almost Every Day
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Suicidal thoughts?
Never
Few Days
Most Days
Almost Every Day
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Self-harm thoughts?
Never
Few Days
Most Days
Almost Every Day
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Worry something awful might happen?
Never
Few Days
Most Days
Almost Every Day
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How confident, making decisions?
Not very confident
Confident
Carer makes decisions for me
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Do you manage your own finances?
Not very confident
Confident
Most Days
No
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Do you worry about your future care?
Never
Few Days
Most Days
Almost Every Day
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Do you undereat?
No
Generally yes
Skip meals
Severely undereat
Bulimia traits
Other
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Do you undereat?
Do you overeat?
No
Generally yes
Severely overeat
Other
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Do you overeat?
Your sleep?
Never sleep
Sleep well
1-2 hours per night
3-5 hours per night
6-8 hours per night
Other
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Your sleep?
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Next
NHS Past Counselling?
Any, Past Counselling?
*
Yes
No
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When? (approx)
Year
How many sessions?
Approx
Any other NHS sessions?
No
Yes
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When? (approx)
Year
How many sessions?
Approx
Any other NHS sessions?
No
Yes
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When? (approx)
Year
How many sessions?
Approx
Experience of NHS Counselling
Good
Did not understand my disability
Poor
Other
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Experience of NHS Counselling
Do you want to add about your counselling experiences?
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Any other counselling?
Self-paid, employer, insurance etc.
Any other counselling?
No
Yes
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Who with?
self-paid, company etc.
Could you add the approx year & how many sessions?
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Anything you want to add?
Would you like to add anything?
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Submit