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Ataxia Questionnaire
Confidentiality
Read Privacy Statement
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Yes
No
Privacy Statement
All information entered on this form is private and confidential. As a mental health service, we prioritise your privacy and the confidentiality of your personal and health information. The details you provide will only be used to support your care and treatment and will not be shared with any third parties without your explicit consent. Your trust is important to us, and we are committed to protecting your privacy in accordance with applicable privacy laws and professional standards.
Who is completing this form?
Please tell us who is completing the form?
*
Myself
Partner
Carer
Mother/Father
Family member
Social services
Other
Other
If one or more people are completing this form multi-select from the answers above.
Contact details of person completing this form
Name
As your GP would know you.
Phone
Email
Reason person who wants counselling cannot complete it.
Inability to use computer/phone/laptop
Person is to distressed to complete it
Person has cognitive issues
Person physically cannot complete it
Other
Other
Your Contact Details (person who wants counselling)
Your Name?
*
PostCode?
*
Date of Birth
Ataxia Type?
Your Ataxia Type?
Episodic
Friedreich’s
Spinocerebellar
Telangiectasia
Other
Other
Cause?
Acquired
Ataxia with vitamin E deficiency
Congenital cerebellar ataxia
Degenerative
Hereditary
Idiopathic late-onset cerebellar
Wilsons
Other
Other
Acquired Causes?
Alcohol
Medications
Toxins
Vitamins
Thyroid problems
Stroke
Multiple sclerosis
Autoimmune diseases
Infections
COVID-19 infection
Paraneoplastic syndromes
Abnormalities in the brain
Head trauma
Cerebral palsy
Multi-Select if needed
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
Any, Additional Disabilities
Do you have any additional disabilities?
Autism
Epilepsy
Hearing Loss
Medical Illness
Sight Loss
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
Other Epilepsy
Best describe what other Epilepsy is
Health
Any Medical Issues?
*
Yes
No
Excluding Ataxia
Medication?
None
Antidepressants
Antipsychotics
Anti-Anxiety
Heart Medication
Diabetes Medication
Mood Stabilisers
Stimulants
Other
Other
Anything to add Medically?
Daily Challenges
Any, Balance Problems
No
Mild
Moderate
Severe
Do you have daily chronic pain?
No
Yes – Mild
Yes – Moderate
Yes -Severe
Other
Other
Any, Swallowing Problems?
No
Mild
Moderate
Severe
Any, Writing Problems
No
Mild
Moderate
Severe
Cannot write
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
Carer Questions?
Do you have a carer?
No
Yes
Other
Other
Is you carer?
Parent
Partner
Social Services
Social Services + Partner
Other
Other
Carer hours?
1-4 hours daily
5 – 8 hours daily
Live-in
Assisted living at home
Assisted living (social services)
Other
Other
Carer supports me with:
Personal hygiene
Dressing
Cooking
Housework
Shopping
Other
Other
Anything to add about carer?
What Would You Like Help With?
Multi-Select Available
Adjustment Disorder
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
If you are human, leave this field blank.
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